Arch Debranching Research Articles

Aortic arch de-branching for suspected expanding perigraft haematoma after previous acute type-A dissection repair with AMDS stent: a technique for a potential future problem

BackgroundAcute Stanford type- A aortic dissections make up a large part of emergency cardiac surgery. They also carry a significant burden of morbidity. New techniques to aid aortic remodelling include the Ascyrus Medical Dissection Stent (AMDS): Its increasing use, looks to present a potential problem in cases where surgery involving the aortic arch may be required.Case reportWe present the case of a 49-year-old male who underwent urgent redo-surgery for total arch replacement and de-branching following recent replacement of the ascending aorta for acute type-A dissection, where an AMDS stent was deployed. The patient underwent total arch replacement with a stented tri-furcate prosthesis and de-branching of arch vessels with the stent landed inside the previous AMDS, to good effect.ConclusionThis case highlights a possible approach to aortic arch surgery in patients who have previous had AMDS insertion.

Staged and segmented two hybrid surgeries for total repair of Debakey type Ⅰ aortic dissection: a series of 10 cases

Objective: To examine the efficacy and experience of staged and segmented two hybrid surgeries for total repair of Debakey type Ⅰ aortic dissection (TIAD). Methods: This study was a retrospective case series. The clinic data of 10 patients with acute TIAD who were admitted to the Department of Cardiac Surgery, Second Hospital of Lanzhou University or the First People's Hospital of Lanzhou, between January 2016 and August 2022, were retrospectively studied. Ten patients underwent hybrid surgeries in two hospitalizations (stages), including 7 males and 3 females with an age of (60±7) years (range: 49 to 71 years). In stage 1, the first type Ⅱ hybrid arch repair was performed to treat the ascending, total arch, and descending thoracic aorta for acute TIAD without circulatory arrest. In stage 2, the second hybrid surgery including infrarenal abdominal aorta replacement, visceral arteries bypass and endovascular thoracoabdominal aortic repair was performed to treat residual thoracoabdominal aortic dissection after the first hybrid operation (segmented). Basic data, preoperative concomitant diseases, high-risk factors, surgical approaches and postoperative complications of all important organs, as well as CT imaging were analyzed. Results: There was no death in the 20 hybrid surgical procedures. In stage 1 type Ⅱ hybrid surgery, 4 cases underwent reconstruction of the aortic sinutubular junction, while Bentall and David surgery was performed for 3 cases, respectively. A patient received coronary artery bypass grafting. Then all patients were sequentially treated with arch debranching and thoracic aortic endovascular repair. Postoperative complications included renal insufficiency (4/10), hemofiltration (1/10), hypoxemia (4/10), neurologic event (1/10) and type Ⅱ endoleak (1/10). Complete false lumen thrombosis occurred in 9/10 of the patients. All complications recovered successfully at discharge and the average hospital stay was (21±4) days (range: 16 to 28 days) in the first hospitalization. At stage 2, the second hybrid surgery was successfully performed in all patients. No paraplegia, hepatic or renal insufficiency, or endoleak occurred. However, branch graft embolism of the left renal artery was found in one patient 3 days after laparotomy, as well as of superior mesenteric artery in another. Superior mesenteric artery occlusion was successfully treated by endovascular recanalization. Complete false lumen thrombosis occurred in all patients. Although all patients had different degrees of intestinal dysfunction, they were gradually relieved at discharge, and the average hospital stay was (19±2)days (range:16 to 21 days) in the second hospitalization. During follow-up, CT angiography showed aortic remodeling in all patients. Conclusion: Staged and segmented two hybrid surgeries are safe and feasible for total repair of Debakey type Ⅰ aortic dissection and are associated with acceptable early and midterm outcomes.

Aortic Arch Debranching and Thoracic Endovascular Aortic Repair (TEVAR) for Type B Aortic Dissection

Since its introduction, thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of type B aortic dissections (TBADs). However, the proximal aspect of the aortic pathology treated may infringe on the origin of the left subclavian artery or even more proximally. Hence, to ensure durable outcomes, the origin of these vessels needs to be covered, but an extra-anatomical bypass is required to perfuse vital branches, known as aortic arch debranching. This series aims to describe and delineate the disparities of aortic arch debranching during TEVAR for TBAD. A retrospective review and analysis of a multicenter international database was conducted to identify patients with TBAD treated with TEVAR between 2005 and 2021. Data analyzed included patient demographics, disease characteristics, operative characteristics, and postoperative outcomes with follow-up on mortality and reintervention. All statistical analyses were carried out using IBM SPSS 26. Patient survival was calculated using a Kaplan-Meier survival analysis, and a P value of less than 0.05 was considered statistically significant. A total of 58 patients were included in the analysis, of which 27 (46.6%) presented with complicated disease and 31 were uncomplicated, of which 10 (17.2%) were classed as high risk and 21 (36.2%) low risk. Zone 2 was the most common proximal landing zone for the stent graft. Left subclavian artery bypass was performed selectively (26%), with 1 stroke occurring, likely due to embolic reasons. A further 6 underwent more proximal aortic debranching before TEVAR (10%) and was a significant risk factor for mortality and the number of stents deployed. The overall rates of reintervention and mortality were 17.2% (n=10) and 29.3% (n=17). Aortic arch debranching and TEVAR for TBAD is associated with significant mortality. Future developments to treat aortic arch pathology could incorporate branched graft devices, eliminating the need for debranching, improving stroke rates, and reducing future reinterventions.

Re-hybrid thoracic stent graft implantation with total aortic arch debranching in urgent procedure: case report

INTRODUCTION: Implementation of emergency endovascular aortic repair provides an opportunity to treat complicated acute aortic syndromes involving descending aorta. CASE REPORT: A 40-year-old man with a history of aortic coarctation surgical repair as a child and an anastomosis aneurysm repair with a double endovascular stent graft implantation with hemi-arch transposition was urgently admitted with intensifying shortness of breath and hoarseness. A computed tomography study confirmed a blood leak into an aneurysm sac in proximal landing zones of implanted stent grafts (Type I endoleak). Therefore, he qualified for hybrid surgery. First, the ascending aorta brachiocephalic trunk was anastomosed with a 12 mm vascular prosthesis from an upper mini-sternotomy. In the next step, normothermic extracorporeal circulation was necessary to prevent cerebral circulation. Finally, a GORE stent graft (Gore Medical, Flagstaff, AZ, USA) was implanted with a proximal landing zone directly behind the anastomosis site of the vascular prosthesis and ascending aorta. The hospital course was uncomplicated, and the patient was discharged home 5 days after the procedure. CONCLUSIONS: Complicated aortic pathologies requiring emergent interventions can be treated by a hybrid approach utilizing multistep surgical and endovascular techniques achieving optimal results.

Chimney thoracic endovascular repair for anastomotic leakage after ascending aortic replacement for acute type A aortic dissection: a case report

Background Anastomotic leakage at the distal anastomotic site after surgery for acute type A aortic dissection (AAD) occasionally leads to malperfusion or false lumen dilatation in the remnant dissected aorta. Open surgery remains the optimal therapy; however, subsequent surgery with re-sternotomy is excessively invasive in elderly and frail patients.Case presentationWe report the case of an 81-year-old woman who was treated with chimney thoracic endovascular aortic repair (TEVAR) for anastomotic leakage after ascending aortic replacement for AAD. A pressure difference between the upper and lower limbs appeared after the primary surgery, and a computed tomography scan showed a stenotic true lumen in the descending aorta due to a “new tear” at the distal anastomotic site. Chimney TEVAR was performed to direct blood flow into the aortic true lumen in order to restore compromised blood flow to lower body because open surgery is excessively invasive for elderly and frail patients. No endoleak and a better expanded true lumen were detected after the subsequent surgical intervention.ConclusionsChimney TEVAR combined with an arch debranching procedure for sealing the new entry at the distal anastomotic site after ascending aortic replacement for AAD may be a viable option for high-risk patients.

Technical tips and clinical experience with the Terumo Relay®Branch aortic endovascular graft

Advances in thoracic endovascular aortic repair (TEVAR) are enabling the treatment of increasingly proximal pathology. While the practice of vascular surgery has thus far been mostly limited to TEVAR in zone 2 or more distally, there are emerging devices for zone 1 and zone 0 repair that do not require any further arch debranching compared with a zone 2 repair. Moreover, such devices set forth repair options for patients unable to tolerate the insult of open surgery. One zone 0 device under evaluation is the Terumo Relay®Branch (Terumo, Tokyo, Japan) endovascular graft, which is an off-the-shelf device based on the Relay®Pro platform (Terumo). This double branch device uniquely features a large gate, facilitating easy cannulation that contains two locking portal stents for the innominate artery (IA) and left common carotid artery (LCCA) branch grafts. Within our institution, we have had excellent technical success with Relay®Branch (Terumo) device deployments as part of the Early Feasibility Study, and other centers outside of the USA have published results with this device in small patient series. Notably, there is still a concerning stroke rate associated with the Relay®Branch (Terumo) device, with permanent stroke rates higher than expected but similar to those for open repair. Thus, these interventions must be undertaken with careful patient selection, thorough planning, and with the guidance of a proficient endovascular aortic team. In this article, we will outline the necessary preoperative workup, highlight device features, and detail the operative strategy, with tips for technical success. These guidelines from our experience will help facilitate successful utilization of this device when it becomes widely available in practice.

Surgery for complications after thoracic endovascular aortic repair with arch vessel debranching: Role of imaging in preoperative planning.

We describe here a series of patients who presented with failed hybrid arch and descending thoracic aortic aneurysm repairs, while highlighting the instrumental role that advanced medical imaging played in formulating an operative plan. Each case involved persistent 1A endoleaks and aneurysm sac growth after hybrid arch repairs tackled by arch debranching followed by thoracic endovascular aortic repair. Two open cases were described as well as one endovascular case. Imaging played a key role in elucidating the site of endoleak and in operative planning. These cases highlight the importance of multidisciplinary input between cardiac surgery, vascular surgery and radiology in management of complex aortic patients.

Early and Midterm Outcomes of Type II Hybrid Arch Repair for Complex Aortic Arch Pathology.

BackgroundThe hybrid arch repair (HAR) is an appealing surgical option in the management of aortic arch diseases. The aim is to evaluate the short and mid-term outcomes of type II HAR involving replacement of the ascending aorta, arch debranching, and zone 0 stent graft deployment in diverse arch pathologies.Methods200 patients with various diffuse aortic pathologies involving the arch were enrolled between 2016 and 2019. Complex arch diseases included acute type A dissection (n = 129, 64.5%), acute type B dissection (n = 16, 8.0%), aortic arch aneurysm (n = 42, 21.0%) and penetrating arch ulcer (n = 13, 6.5%). Mortality, morbidity, survival and re-intervention were analyzed.ResultsThe overall 30-day mortality rate was 8.0% (16/200). Stroke was present in 3.5% (7/200) of the general cohort and spinal cord injury was occurred in 3.0% (6/200). Multivariable logistic analysis showed that cardiac malperfusion and CPB time were the risk factors associated with 30-day mortality. The mean follow-up duration was 25.9 months (range 1–57.2 months), and the 3-year survival rate was 83.1%. On Cox regression analysis, age, diabetes, cardiac malperfusion and CPB time predicted short and mid-term overall mortality. A total of 3 patients required reintervention during the follow-up due to the thrombosis of epiaortic artificial vessels (n = 1), anastomotic leak at the site of the proximal ascending aorta (n = 1) and the type I endoleak (n = 1).ConclusionsType II HAR was performed with satisfactory early and mid-term outcomes in complex aortic arch pathologies.

DUPLICATE: Combined Stroke and Spinal Cord Infarction in Hybrid Type I Aortic Arch Debranching and TEVAR and the Dual Role of the Left Subclavian Artery

AORTIC ARCH pathology, as a part of acute aortic syndrome, is a difficult clinical problem to address. Whether it presents as an intramural hematoma with impending rupture, isolated aneurysmal disease, or acute localized dissection, it creates a clinical challenge to the perioperative team. Some of the difficulty stems from determining the best operative strategy, either an open approach, total endovascular repair, or a hybrid of the two. Hybrid aortic arch repair involves 2 steps—open aortic branch revascularization and endovascular aortic repair. 1 Gregory AJ Prusinkiewicz CA Herget E et al. Subclavian graft thrombosis as an alternative cause for delayed spinal cord ischemia following hybrid aortic arch repair. J Cardiothorac Vasc Anesth. 2014; 28: 718-722 Google Scholar Variations of these 2 steps may be used. Each involves its own set of risks.

Short-term results of off-pump and on-pump aortic arch debranching during type I hybrid arch repair: A single-center experience

BackgroundCompared with off-pump surgeries, cardiopulmonary bypass (CPB) is associated with a high systemic inflammatory response and with substantial myocardial injury, especially in high-risk subgroups. Every effort should be exerted to minimize the role of CPB without affecting the safety and outcome. Classically, aortic arch surgeries were done using CPB and deep circulatory arrest together with cerebral brain protection strategies. With the development of endovascular techniques, the role of CPB decreased. Management of aortic arch pathologies carries special needs, specifically rerouting of the great vessels and preparing a landing zone.ObjectivesTo assess the effectiveness and safety of off-pump aortic arch debranching during type I hybrid aortic arch repair.Patients and methodsWe report our single-center experience of rerouting aortic arch branches (debranching) without using CPB, consisting of bypass grafting of the aortic arch branches off pump, preparing a landing zone for endovascular aortic repair. The preoperative, operative, and postoperative data were collected and analyzed retrospectively. Starting from 2015, 20 low-risk patients were subjected to type I aortic arch hybrid repair, whereas the Dacron tube graft was anastomosed to a normal ascending aorta, preparing a landing zone to the subsequent stenting of arch and descending aorta. CPB was used in 10 patients, and off-pump technique was used in the remaining group. Preoperative, operative, and postoperative data were collected and analyzed to compare the results.ResultsAll surgeries went uneventful, with mean operative time of 141.5 ± 24.3 min for group I (on-pump group) and 137.5 ± 14.6 for group II (off-pump group). There were no conversions to CPB in off-pump group. There was no sternotomy for bleeding in off-pump group, compared with only one patient explored for postoperative bleeding in CPB group. All patients in both groups went without any neurological deficit of significance, with no mortality in the 30 days of follow-up.ConclusionOff-pump debranching of aortic arch followed by endovascular repair is a safe and reproducible technique, compared with the gold standard technique using CPB. However, further efforts using intraoperative cerebral perfusion monitoring techniques should be considered in the future.

Aortic arch debranching in hybrid thoracic aortic replacement

To analyze the outcomes of aortic arch debranching in hybrid thoracic aortic replacement. There were 107 patients who underwent hybrid thoracic aortic repair with debranching of supra-aortic vessels between 2015 and 2021. Patients underwent total and partial debranching (subtotal debranching and subclavian-carotid anastomosis/bypass). Debranching was performed in patients with type 3 dissection, type B aneurysms, post-traumatic aortic isthmus and arch aneurysms, thoracoabdominal aneurysms type A and DeBakey type 1 dissections. One patient (0.9%) died from thoracic aorta rupture after retrograde dissection. There was a moderate decrease of blood flow velocity through the left vertebral artery after subtotal debranching without severe hemodynamic disorders. Despite mild surgical trauma, subtotal and especially total debranching are characterized by higher risk of thrombosis of branches with potential fatal outcomes. In young patients requiring subtotal aortic arch debranching, open reconstruction or repair with fenestrated stents is preferred. We recommend a Bavaria type II hybrid procedure for patients with high surgical risk. In our opinion, more physiological hybrid interventions with anatomical arrangement of supra-aortic vessels such as Elephant Trunk and Frozen Elephant Trunk procedures are preferred.

Time-resolved, Cardiac-gated Computed Tomography After Endovascular Ascending Aortic and Arch Repair

PurposeBetter time-resolved imaging of stent grafts in the ascending aorta and arch accounting for cardiac motion is necessary to understand device-related complications and endoleaks. This report describes dynamic time-resolved computed tomographic angiography (d-CTA) and its combination with electrocardiography gating (d-gated CTA) to image stent grafts in the ascending aorta and to characterize endoleaks more clearly. Descriptiond-CTA involves multiple scans acquired at different time points along the contrast enhancement curve. d-Gated CTA involves concomitant electrocardiography gating in a predefined cardiac phase minimizing motion-induced artifacts. EvaluationThis report illustrates the utility of d-CTA and d-gated CTA in 2 clinical cases. d-CTA demonstrated a type 1A endoleak in a patient with an aortic arch aneurysm treated with total arch debranching and a thoracic stent graft. d-gated CTA demonstrated a type 1A endoleak in a patient with an ascending aortic pseudoaneurysm treated with aortic cuff placement. ConclusionsDynamic, cardiac-gated CTA enables time-resolved angiographic imaging of the ascending aorta and arch without any cardiac motion–related artifacts. Such advanced imaging techniques help with better characterization of endoleaks after stent graft deployment in the ascending aorta and arch.

Comparison of early outcome between one-stage hybrid technique and frozen elephant thunk technique in the treatment of Stanford A aortic dissection involving the arch

Objective: To analyze the early outcome of one-stage hybrid technique in the treatment of Stanford type-A aortic dissection involving the arch and compare its therapeutic efficacy with the classical frozen elephant trunk technique (FET). Methods: A total of 106 patients with Stanford type-A aortic dissection involving the arch in Department of Cardiac and Vascular Surgery, 1st Affiliated Hospital of Soochow University from October 2015 to October 2019 was collected. All patients in this group were treated with one-stage hybrid technique (modified arch debranching technique) without deep hypothermia circulation. Meanwhile, 30 patients with Stanford type A dissection involving the arch who underwent FET from January 2014 to September 2015 were collected. The therapeutic effects of the two surgical methods were analyzed and compared. Results: The age [M (Q1, Q3)] of 106 patients in hybrid group was 49.0 (40.0, 55.0) years, including 89 males and 17 females. The age [M(Q1, Q3)] of 30 patients in FET group was 49.5 (41.5, 65.3) years, including 24 males and 6 females. The time [M(Q1, Q3)] of using ventilator in hybrid group was 56.0 (38.0, 72.0) h, which was shorter than 127.0 (92.0, 145.0) h in FET group (P<0.001). The incidence of cerebral infarction in hybrid group was 2.8% (3 cases), which was lower than 13.3% (4 cases) in FET group (P=0.042); the incidence of postoperative renal insufficiency in hybrid group was 7.5% (8 cases), which was lower than 23.3% (7 cases) in FET group (P=0.023); the ICU time [M (Q1, Q3)] in hybrid group was 8.0 (6.0, 10.0) d, which was shorter than 14.0 (8.3, 24.0) d in FET group (P<0.001). Conclusion: Compared with FET, one-stage hybrid technology is safer and more effective in the treatment of Stanford type A aortic dissection involving the arch. Its short-term therapeutic efficacy appears good.

Efficiency of hybrid surgical treatment of the aortic arch and descending thoracic aorta aneurysm

OBJECTIVE. Assessment of the mid-term results after various types of debranching in hybrid surgery of the aortic arch and descending thoracic aorta.METHODS AND MATERIALS. 47 patients with various pathologies of the aortic arch and descending thoracic aorta were operated on. Six of them suffered from type IIIa dissection and 26 from type IIIb dissection according to DeBakey classification, 15 patients had true aortic aneurysms. The following interventions were performed: total aortic arch debranching (n=5), cross subclavian-subclavian-left-common carotid (n=14) or cross carotid-carotid-subclavian bypass (n=7); subclavian-carotid transposition or bypass (n=12); Chimney technique for the aortic arch aneurysm (n=8); in situ fenestration of the endoprosthesis (n=1). Elective surgery was performed in 32 patients, emergency in 15.RESULTS. Technical success achieved in 100 %. The overall hospital mortality rate was 10.6 % (n=5), elective surgery mortality rate was 9.3 % (n=3), in emergency cases - 13.3 % (n=2). Causes of mortality: stroke (n=1), multiple organ failure after prosthetic ascending aorta due to retrograde dissection after stent graft implantation (n=1), pneumonia (n=1), acute myocardial infarction (n=1), profuse bleeding (n=1). Cumulative survival rate was 87.5 % over 5 years, freedom from reinterventions - 89.1 %. During the first year of observation, 3 patients underwent stent graft replacement of the descending thoracic aorta due to formation of a dissection below the primary stent graft (n=1), open prosthesis of the ascending aorta due to it retrograde dissection (n=1), endofixation of the stent graft with embolization of the false lumen (n=1).CONCLUSION. Hybrid surgery on the aortic arch and the descending thoracic aorta is safe and effective treatment. Regular follow-up and timely treatment of complications in the long term after hybrid or endovascular interventions are necessary to improve long-term results.

Hybrid Surgery to Manage Aortic Arch Pathology.

Background and Objectives: Aortic arch disease is still a high-risk surgical challenge despite major advances both in surgical and anesthesiological management. A combined surgical and endovascular approach has been proposed for aortic arch disease treatment to avoid hypothermia and circulatory arrest in high-risk patients. Materials and Methods: Between June 2004 and June 2021, 112 patients were referred to our department for aortic arch surgery; 38 (33.9%) patients underwent supra-aortic debranching and endovascular treatment. Of these, 21 (55%) patients underwent type I aortic arch hybrid debranching procedure and in 17 (45%) patients a type II aortic arch hybrid debranching procedure was performed. None of the patients were emergent. Results: No intra-operative deaths were recorded. In the type I aortic arch hybrid debranching patients’ group, one patient died at home waiting the endovascular step, one developed ascending aortic dissection and another one developed a pseudoaneurysm at the site of the debranching at follow-up. In the type II aortic arch hybrid debranching patients’ group, left carotid artery branch closure was detected at follow-up in one patient. Thirty day/in-hospital rates of adverse neurological events for both the surgical and endovascular procedures were 3% for minor stroke, with no permanent neurological deficit and 0% for permanent paraplegia/paraparesis. In 100% of the cases, the endovascular step succeeded and the type Ia endoleak rate was 0%. Conclusions: Hybrid arch surgery is a valuable option for aortic arch aneurysm treatment in patients with high surgical risk. The choice of aortic arch debranching between type I or type II is crucial and depends on anatomic and clinical patient characteristics. Further larger scale studies are needed to better define the advantages of these techniques.

Combined Stroke and Spinal Cord Ischemia in Hybrid Type I Aortic Arch Debranching and TEVAR and the Dual Role of the Left Subclavian Artery

AORTIC ARCH PATHOLOGY, as a part of acute aortic syndrome, is a difficult clinical problem to address. Whether it presents as an intramural hematoma with impending rupture, isolated aneurysmal disease, or acute localized dissection, it creates a clinical challenge to the perioperative team. Some of the difficulty stems from determining the best operative strategy, either an open approach, total endovascular repair, or a hybrid of the two. Hybrid aortic arch repair involves two steps: open aortic branch revascularization and endovascular aortic repair. 1 Gregory AJ Prusinkiewicz CA Herget E et al. Subclavian graft thrombosis as an alternative cause for delayed spinal cord ischemia following hybrid aortic arch repair. J Cardiothorac Vasc Anesth. 2014; 28: 718-722 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Variations of these two steps may be used. Each involves its own set of risks.

A Rare Case of an Ascending Aorta and Aortic Arch Aneurysm with an Aberrant Right Common Carotid Artery

Ascending aortic aneurysms are asymptomatic and are usually discovered as an incidental finding on chest imaging. However, larger aneurysms can present with symptoms resulting from compression of surrounding structures including the trachea, bronchi, and the esophagus which can result in hoarseness, cough chest pain or back pain. The presence of an aortic arch anomaly, specifically an aberrant right common carotid artery, in a background of an aortic arch aneurysm is extremely rare with a worldwide incidence of &lt;1%. They are usually asymptomatic but can result to catastrophic life threatening events and pose significant challenges to surgical or endovascular treatment. This is a case of a 63-year old Filipino male who presented with a sudden onset of dull back pain radiating to the left anterior chest. Workup revealed an ascending and aortic arch aneurysm with an aberrant right common carotid artery arising directly from the transverse aorta. Surgical aortic arch debranching was done to repair the aberrant vessels prior to Thoracic Endovascular Aortic Repair (TEVAR) wherein a custom-made Thoracic Valiant graft was deployed on the aneurysm. The patient was discharged on the 4th day after TEVAR without any complaints of dyspnea, back pain nor chest pain with no neurologic and visceral organ dysfunction. This case has emphasized that knowledge on the anatomy of the aortic arch is imperative in planning out thoracic surgery and endovascular interventions especially on rare anatomic anomalies such as seen in this case. Keywords aortic aneurysm, aberrant right common carotid artery, TEVAR

Early results of combined aortic arch debranching and thoracic endovascular re-pair

Background: The hybrid technique for managing aortic arch diseases has been introduced recently into the surgical armamentarium. We aimed to evaluate the early postoperative outcomes after aortic arch debranching and endovascular repair (TEVAR) of aortic arch aneurysms or dissection.&#x0D; Methods: Between March 2015 and September 2020, 17 patients underwent elective aortic arch debranching concomitant with TEVAR. Thirteen patients had aortic arch aneurysms, and four had chronic dissection. Study outcomes were early postoperative complications such as stroke, paraplegia, renal insufficiency, and 30-day mortality.&#x0D; Results: The mean age of our patients was 61.2± 7.6 years; 12 of them were males (70.6%). Five patients underwent total debranching (29.4%). All debranching procedures were followed with TEVAR. 30-day mortality, stroke, permanent paraplegia, and renal failure occurred in one patient (5.9%), while transient neurological deficit occurred in two patients (11.8%).&#x0D; Conclusion: Hybrid management of aortic arch pathologies showed encouraging early results. The combination of surgical aortic arch debranching and TEVAR could be an option for managing aortic arch diseases. However, larger studies with longer follow up are recommended.

Complex endovascular repair of type B aortic dissection and predicting left arm ischemia: a case report

BackgroundThoracic endovascular aortic repair (TEVAR) is the gold standard for surgical management of descending thoracic aortic pathology. Depending on the anatomy, TEVAR often requires deployment across the origin of the left subclavian artery (LSA) to obtain a proximal seal, thus potentially compromising perfusion to the left upper extremity (LUE). However, in most patients this is generally well tolerated without revascularization due to collateralization from the left vertebral artery (LVA).Case presentationWe present a complex 59-year-old Caucasian patient case of TEVAR with a history of prior arch debranching and intraoperative LSA coverage requiring subsequent LSA embolization and emergency take-back for left carotid–subclavian bypass.ConclusionThe purpose of this case report is to highlight an often overlooked anatomic LVA variant and an atypical, delayed presentation of acute LUE limb ischemia.

National Outcomes of Elective Hybrid Arch Debranching with Endograft Exclusion versus Total Arch Replacement Procedures: Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database.

Objective Hybrid arch procedures (arch vessel debranching with thoracic endovascular aneurysm repair [TEVAR] coverage of arch pathology) have been presented as an alternative to total arch replacement (TAR). But multicenter-based analyses of these two procedures are needed to benchmark the field and establish areas of improvement. Methods The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database from July 2014 to December 2015 was queried for elective TAR and hybrid arch procedures. Demographics and operative characteristics were compared and stepwise variable selection was used to create a risk-set used for adjustment of all multivariable models. Results A total of 1,011 patients met inclusion criteria, 884 underwent TAR, and 127 had hybrid arch procedures. TAR patients were younger (mean age: 62.7 ± 13.3 vs. 66.7 ± 11.9 years; p = 0.001) and had less peripheral vascular disease (34.0 vs. 49.6%; p < 0.001) and preoperative dialysis (1.7 vs. 4.7%; p = 0.026), but similar history of stroke ( p = 0.91)/cerebrovascular disease ( p = 0.52). TAR patients had more concomitant procedures (60 vs. 34.6%; p < 0.0001). TAR patients had lower mortality (6.7 vs. 12.6%; p = 0.02), stroke (6.9 vs. 15%; p = 0.002), paralysis (1.8 vs. 7.1%; p = 0.002), renal failure (4.6 vs. 8.7%; p = 0.045), and STS morbidity (34.2 vs. 42.5%; p = 0.067). Composite mortality, stroke, and paralysis were significantly lower with TAR (11.5 vs. 25.2%; p = 0.0001). After risk adjustment, analysis showed hybrid arch procedures imparted an increased odds of mortality (odds ratio [OR] = 1.91, p = 0.046), stroke (OR = 2.3, p = 0.005), and composite endpoint of stroke or mortality (OR = 2.31, p = 0.0002). Conclusion TAR remains the gold standard for elective aortic arch pathologies. Despite risk adjustment, hybrid arch procedures were associated with increased risk of mortality and stroke, advocating for careful adoption of these strategies.