Distal Arch Aneurysm Research Articles

Clinical results of open stent grafting applied using an improved endotracheal tube in the treatment of high-risk patients with distal arch aneurysms

Whereas the operative results for thoracic aortic aneurysms (TAA) have improved in recent years, the results for distal arch aneurysms (DAA) remain unsatisfactory. We report herein the initial results of open stent grafting (OSG) applied using an improved endotracheal tube for surgical treatment of high-risk DAA. OSG was used to treat DAA in five men aged 69-80 years (mean, 77 years). Four cases involved chronic obstructive pulmonary disease, and the remaining case involved both ischemic heart disease and chronic renal failure. Previous surgical repairs of an abdominal aortic aneurysm had been performed in four patients, and thoracoplasty and reconstruction of the lower extremities had been performed in the remaining patient. Under selective cerebral perfusion, OSG with revascularization of two cerebral branches was performed in two patients, whereas OSG with total arch replacement was performed in three patients. The procedure was successful in all cases. There were no complications related to cerebrospinal disorders, and complete thrombosis of the aneurismal sac was achieved in all cases. The new deployment method using an endotracheal tube offers numerous advantages, including reduced aortic wall injury and accurate placement of the stent graft in the operative field. These initial results suggest that this specific approach makes OSG a useful surgical procedure in the treatment of high-risk DAA.

Surgical repair of a distal arch aneurysm with a stent-graft.

This study evaluates the effectiveness and potential complications of stent-grafting for the treatment of distal arch aneurysms using profound hypothermia and circulatory arrest with retrograde cerebral perfusion. Between December 1998 and December 2001, 9 consecutive patients with a distal arch aneurysm (6 men and 3 women, mean age 71 years) underwent surgical repair using a stent-graft. Profound hypothermic circulatory arrest and retrograde cerebral perfusion were performed in all patients. Endovascular leakage was screened postoperatively using three-dimensional computerized tomography. The mean follow-up period was 27.4 months. Thirty day mortality was 0%. One patient died 3 months after stent-grafting due to proximal leakage into her aneurysm. The mean postoperative extubation period was 2.1 days. No patients suffered cerebral infarction or paraplegia. Although preliminary outcomes using this technique were good, endovascular leakage is a concern. We suggest that, if major proximal leakage is recognized postoperatively, re-intervention should be performed as soon as possible. Endovascular stent-grafting appears to be a good alternative treatment for distal arch aneurysms, although longer follow-up is necessary to more comprehensively evaluate this procedure.

Endografting facilitated by axillary-axillary bypass for distal arch aneurysm after left internal thoracic artery to left anterior descending artery bypass surgery

J Thorac Cardiovasc Surg 2003;125:950-2

Cerebrospinal dysfunction after endovascular stent-grafting via a median sternotomy:the frozen elephant trunk procedure

Background Endovascular stent grafting through a median sternotomy for a distal arch aneurysm (the frozen elephant trunk procedure) is an alternative to synthetic graft replacement. But spinal cord dysfunction can easily occur as a complication after surgery. Although its cause is uncertain, some attempts at prevention have been instituted. We address the mechanism of spinal cord dysfunction and evaluate the efficacy of our preventive measures. Methods There were 22 men and 2 women with an average age of 71 (59 to 83) years. There were 22 true aneurysms (13 fusiform, nine saccular), one chronic dissection, and one penetrating aortic ulcer. The following strategies for prevention of spinal cord dysfunction were utilized: low flow perfusion through both axillary arteries (n = 10); pigtail catheter guidance (n = 19); use of a shorter graft with anchoring sutures (n = 12); flooding of the operative field with carbon dioxide (n = 7); aortic unclamping (n = 7), and use of ultra-thin woven Dacron grafts (n = 15). Results There was no operative mortality, but cerebrospinal dysfunction complicated four cases (17%): one paraplegia, one stroke along the basilar artery, and two cases of temporary spinal cord dysfunction (paresthesia of the right leg and urinary disturbance). Cerebrospinal dysfunction tended to occur in fusiform aneurysms (31%, p = 0.044). Except when low flow antegrade perfusion through both the axillary arteries was utilized, which resulted in no cases of paraplegia or paraparesis ( p = 0.064), the methods used for prevention of cerebrospinal dysfunction appeared to have little efficacy. Conclusions Cerebrospinal dysfunction is a serious complication of the frozen elephant trunk procedure. Its cause has not been clarified, but it tends to occur in fusiform-type aneurysms. Antegrade perfusion through both axillary arteries while the aorta is open may be helpful in its prevention.

A new concept in distal arch aneurysm repair with a stent graft

A new concept in distal arch aneurysm repair with a stent graft

Comparative clinical study between endovascular stent grafting on open surgery and conventional graft replacement for distal arch aneurysm

The clinical results of endovascular stent grafting (EVG) on open surgery for distal aortic arch aneurysm were compared with those of conventional graft replacement to evaluate the lesser degree of invasiveness of EVG. Thirteen men with an average age of 68±6 years under-went EVG. Total arch replacement was performed in one and aortocoronary bypass grafting was combined in two. The controls were 12 men and one woman with an average age of 69±5 years. Surgery were performed via midsternotomy in seven and via left thoracotomy in six. Total arch replacement was performed in five. The operation time in the EVG group was shorter than that in the control group (410±88 vs. 515±147 min). There were no significant differences between the groups in bypass time (228±57 vs. 209±39 min) and circulatory arrest time (42 ±8 vs. 44±14 min). The blood transfusion rate was 31% in the EVG group and 77% in the control group. Long-term respiratory support was required in one EVG patient, compared with 46% of control patients. There was no operative mortality, but paraplegia occurred in one patient, cerebral infarction in one, and temporary partial spinal cord dysfunction in two in the EVG group. In the control group, one patient died of stroke, three had cerebral infarction, two had low output syndrome, one had sepsis, and one had gastrointestinal bleeding. EVG on open surgery had a shorter operative time, lower blood transfusion rate, and shorter respiratory support time. These results suggest that EVG is less invasive. However, further improvement is required to prevent complications.

Endovascular stent-grafting via the aortic arch for distal aortic arch aneurysm: an alternative to endovascular stent-grafting.

We have experienced transaortic stent-grafting for treating distal arch aneurysm or type B dissection. This paper is to mainly report the surgical aspect of these procedures. Fifteen patients underwent this surgery, including 12 men and three women ranging from 47 to 83 years. Twelve had aneurysms and three aortic dissection. Concomitant surgery was necessary in seven patients (coronary artery bypass grafting in five, tricuspid annuloplasty in one, and replacement of ascending aorta and/or total arch replacement in three cases). A stent graft (Gianturco Z-stent and Intervascular prosthesis) was loaded in a 30-F sheath catheter. Under circulatory arrest, selective cerebral perfusion was established, and the sheath catheter was inserted through aortotomy into descending aorta and the stent graft was deployed at an appropriate level. The proximal end of graft was sutured to the aorta just distal to the left subclavian artery with inclusion method at the posterior wall. Concomitant surgery was done during cooling or rewarming period. TEE was utilized to visualize every endovascular manipulation to avoid unintended intimal injury or misplacement of graft and to assess the surgical results in the operative theater. Aneurysm was successfully excluded except in one patient who had a proximal endoleak and distal endoleak due to underestimation of aortic diameter. There was one operative mortality caused by cerebral infarction, possibly due to debris from femoral arterial cannulation. In the remaining patients, there was no enlargement of residual aneurysm. The excluded aneurysmal sac gradually regressed and disappeared within 2 years in five patients and the thrombosed false lumen completely shrunk within 1 year in two patients. One patient had paraplegia, possibly because the graft was intentionally advanced deeply to cover the thick and fragile atheromatous layer in order to avoid destruction of the atheroma by an expanded graft. Endovascular stent graft via the aortic arch is an acceptable treatment for distal arch aneurysms close to or involving left subclavian artery or type B dissections, especially for those cases requiring other cardiac procedures. It can lead to regression and disappearance of aneurysm or dissection in the mid-term follow-up.

Shrinkage of excluded aneurysmal spaces: The excellent results of endovascular stent grafting through the aortic arch for distal arch aneurysm

Shrinkage of excluded aneurysmal spaces: The excellent results of endovascular stent grafting through the aortic arch for distal arch aneurysm

Atherosclerotic aneurysm in the circumflex retroesophageal right aortic arch

A 63-year-old man had a distal arch aneurysm combined with a circumflex retroesophageal right aortic arch, which is a rare form of vascular ring. By using combined median sternotomy and left thoracotomy under deep hypothermia and retrograde cerebral perfusion, total arch replacement with a vascular graft was successful. We describe our surgical strategy for arch aneurysm associated with an uncommon congenital vascular malformation.

Distal arch aneurysm repair using stent-grafting and ascending aorto-left axillary bypass

Background. Transcatheter application of a stent-graft to the angulated aortic segments with critical side branches poses some problems. We report our technique of distal arch aneurysm repairs using stent-grafts inserted through the aortic arch and ascending aorto-axillary bypass. Patients and Results. Three patients underwent successful distal arch aneurysm repair using a homemade semiflexible stent-graft placed under hypothermic circulatory arrest. The left subclavian artery was reconstructed by an extraanatomic bypass grafting between the ascending aorta and left axillary artery. Postoperative imaging demonstrated reduction of aneurysm size and no endoleaks from an intercostal artery. Conclusions. Our technique seems to be useful for repair of distal arch aneurysms and is a less invasive procedure.

Predictive factors for mortality and cerebral complications in arteriosclerotic aneurysm of the aortic arch

Background. The incidence of cerebral complications is high in patients with aortic arch aneurysm. Methods. Between December 1977 and December 1995, 246 patients with arteriosclerotic arch aneurysm underwent operation. Thirty-nine patients had an aneurysm involving the entire arch, 193 had only distal arch aneurysm, and 14 had arch aneurysm extending to the descending aorta. Eighty-seven patients underwent replacement of the total arch, 85 had replacement of only the distal arch, 14 had simultaneous replacement of the descending aorta, 45 had patch repair, and 15 had thromboexclusion. Selective cerebral perfusion was used in 112 patients and partial bypass in 58 in the earlier series of patients, but deep hypothermic circulatory arrest with retrograde cerebral perfusion technique was exclusively applied in the most recent 76 patients. Results. There were 50 (20%) early deaths and 37 (19%) late deaths. Postoperative stroke was found in 26 (11%) patients of which 13 (50%) died. Mutual predictive factors for postoperative mortality and stroke were earlier series, preoperative chronic renal failure, ruptured aneurysm, arch clamping during procedure, and using partial cardiopulmonary bypass. Among 129 patients operated on during the most recent 5 years, early mortality and incidence of stroke decreased to 14.7% and 6.9%, respectively. Conclusions. Results of operations for arteriosclerotic aneurysms of the transverse aortic arch in 246 patients during a period of 17 years have been improving but are still not satisfactory.

Impact of Retrograde Cerebral Perfusion With Posterolateral Thoracotomy on Distal Arch Aneurysm Repair

Background. Repair of distal aortic arch aneurysms is difficult to accomplish through a median sternotomy or left thoracotomy, and stroke and respiratory disorders often become lethal complications with the use of circulatory arrest. We investigated the use of retrograde cerebral perfusion with a posterolateral thoracotomy in the repair of distal arch aneurysms. Methods. Thirty-eight patients underwent repair of a distal arch aneurysm. They were divided into three groups according to the method of surgical repair used. Sixteen patients (group I) underwent proximal anastomosis of the graft with the use of an aortic cross-clamp. Eight patients (group II) underwent open proximal anastomosis with the use of retrograde cerebral perfusion (oxygenated blood perfusion through a superior vena cava cannula) and a median sternotomy and anterolateral thoracotomy. Fourteen patients (group III) also underwent open anastomosis with the use of retrograde cerebral perfusion (cerebral perfusion through blood returned to the right atrium with the patient in the Trendelenburg position) and a posterolateral thoracotomy. Results. The operative mortality rate in group I was 25.0%; 4 of 16 patients died of stroke, myocardial infarction, and intestinal necrosis. In group II, 3 of 8 patients (37.5%) died of respiratory failure and aortic dissection. In group III, only 1 of 14 patients (7.1%) died, as a result of heart failure. Conclusions. The use of retrograde cerebral perfusion with a posterolateral thoracotomy is an alternative method that minimizes the risk of stroke and respiratory failure during distal aortic arch operations.

心拍動下にパッチ閉鎖術を施行した遠位弓部大動脈りゅうの２症例

心拍動下にパッチ閉鎖術を施行した遠位弓部大動脈りゅうの２症例

Operative strategy for distal arch aneurysms — effectiveness of intraoperative echography

Operative strategy for distal arch aneurysms — effectiveness of intraoperative echography

Total arch replacement for distal arch aneurysm in a severe atherosclerotic aorta

Total arch replacement for distal arch aneurysm in a severe atherosclerotic aorta

Ｎｏｎ‐ｃｌａｍｐｉｎｇ ｓｅｌｅｃｔｉｖｅ ｃｅｒｅｂｒａｌ ｐｅｒｆｕｓｉｏｎ法による遠位弓部大動脈りゅう手術

Ｎｏｎ‐ｃｌａｍｐｉｎｇ ｓｅｌｅｃｔｉｖｅ ｃｅｒｅｂｒａｌ ｐｅｒｆｕｓｉｏｎ法による遠位弓部大動脈りゅう手術

下行胸部大動脈りゅうの手術成績 とくに遠位弓部大動脈りゅう手術の問題点について

下行胸部大動脈りゅうの手術成績 とくに遠位弓部大動脈りゅう手術の問題点について