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Sumario Vol. 42 - Nº 2 Abril - Junio 2013

Entire Thoracic Aorta Replacement
by Hybrid Procedure in Two Stages

Alberto J. Canestri, Guillermo J. Pacheco,
Javier Blanco, Walter A. Quiroga Castro

Instituto Modelo de Cardiología.
Sagrada Familia 359. Córdoba (5003), Argentina.
Correo electrónico

The authors declare not having a conflict of interest.
 


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SUMMARY

The appropriate treatment for aneurysmal disease of the thoracic aorta represents a great challenge, specially when it compromises great extensions of this vessel. The open surgical procedures were the "gold standard" and single option several years ago but carrying ahigh risk of morbimortality even in the best hands. The current utilization of the endovascular procedures gave birth to what is called "the Hybrid procedures" that changed this severe prognosis. A case report of this approach is presented.

Key words: Thoracic Aortic Aneurysm. Hybrid Procedures. Endovascular treatment.
Rev Fed Arg Cardiol. 2013; 42(2): 141-145

 

 

INTRODUCTION
The patients with widespread dilatation of aorta (mega-aorta syndrome) represent a true therapeutic challenge [1]. Up to the advent of the endovascular procedures, the treatment of aneurysmatic disease of the aorta was exclusively surgical, and received a considerable impulse with the introduction –since 1981- of the “elephant trunk” technique by Hans Borst, which allowed an approach in stages with the subsequent improvement of the results [2].

Anyway, the treatment entails –even in the best of hands- a considerable risk of mortality and paraplegia [3], when the treatment is approached from the descending aorta.

The advent and improvement over the last two decades of the use of coated stents in the descending aorta and its use in combination with the surgical treatment (hybrid or combined procedures) has allowed to deal with this complex pathology with a better perspective. The description of one of them constitutes the reason for this presentation.


CLINICAL CASE
Female, 66-year-old patient, HTN diagnosed 6 years ago, former smoker and hereditary and familial history of CAD. A year ago she presented an intense pain in left inter-scapulo-vertebral region, that yielded spontaneously. She consulted with her family doctor who requested computerized axial tomography (CAT) of chest, that reports aorta aneurysm of 45 mm. It was decided to wait and follow-up with imaging. She remained asymptomatic until February this year, when the chest pain returned, with similar characteristics as before, accompanied by weakening. A new CAT reports increase in the size of the aneurysm (55 mm) so she is referred for interconsultation with this service.

In the physical examination, regular heart rate of 60 bpm was verified; BP: 150/90 mmHg, peripheral pulses present and symmetrical. Palpitations and/or chest fremitus. Cardiac auscultation revealed diastolic murmur of 1/6 intensity in aortic focus. The basal ECG showed sinus rhythm, 60 bpm, QRS axis +30º, QRS 0.06 sec and PQ intervals 0.10 sec, and QT 0.36 sec.

The patient came to the medical office with the following imaging studies:
Chest CAT with contrast (June 11, 2011) that reports voluminous aneurysm of ascending aorta (AscAo) extending to the arch and descending aorta (DescAo), mostly in its portion adjacent to the left subclavian artery (LSA). The AscAo diameter is 50 mm; that of the proximal arch is 42 mm, and that of the distal arch 50 mm. In the juxta-subclavian portion, the AscAo is 49 mm, 40 mm in the middle third and 35 mm in the distal portion and onset of abdominal aorta. The aorta recovers its normal caliber at the level of the origin of the superior mesenteric artery (23 mm).

Another CAT with contrast (September 28, 2011), the commentary of which is: “aorta dilatation, which has not varied significantly in regard to the last tomographic study”.

Aortogram and cine coronary angiography (CCA) dated from February 29, 2012, reports aneurysm of thoracic ascending aorta of 60 mm and proximal descending aorta 70 mm, mobile and competent tricuspid aortic valve.

CAT with contrast (March 19, 2012) by another operator, reports thoracic aorta dilated throughout its chest trajectory, measuring 50 mm in the ascending aorta, 45 mm in the arch, and 45 mm in the descending aorta with the presence of wall thrombosis posterior to this level, spindle-shaped dilatation of suprarenal aorta that continues with thoracic aorta dilatation. Anatomical variant of the bovine arch type. 3D reconstruction of the multi-slice CAT of the thoracoabdominal aorta shows the extent of the aneurysmatic disease (Figure 1).

Figure 1. 3D reconstruction (multislice CAT) of thoracoabdominal aorta, showing the aneurysmatic disease and its extension.

 

Transthoracic echo (TTE) from the same date showed preserved ventricular function, mild tricuspid valve insufficiency, and mild aortic valve insufficiency.

Due to the recurrence of symptoms and the caliber, especially at the level of the descending aorta, with diagnosis of aneurysm of thoracic and abdominal aorta, interconsultations were made with the services of cardiovascular surgery and interventional cardiology.

With the opinion and information obtained from the interconsultations made, it was decided to treat all the thoracic aorta and onset of the abdominal aorta by hybrid procedure in two stages: the first surgical, to replace the ascending aorta and aortic arch, opting for this for a debranching technique of the supra-aortic vessels instead of the frozen elephant trunk, for reasons that will be explained later.

On April 24, 2012, in the surgical act by median sternotomy, the ascending aorta aneurysm and arch are seen (Figure 2), proceeding to the cannulation of the right axillary artery with 8 mm graft with dissection and isolation of the innominate vein and the supra-aortic vessels (Figure 3). Venous cannulation with single cava and right superior pulmonary artery for the aspiration of the left chambers and cannulation of the venous sinus for infusion of cardioplegic solution.Later, extracorporeal circulation (ECC)pump is connected and cooling starts, with aortic clamping and infusion of 2000 cc of HTK cardioplegic solution (Rivero) for 6 minutes by anterograde and retrograde pathways for a proper myocardial protection. With longitudinal incision of ascending aorta, the aortic root and aortic valve is explored, which were normal. The aneurysm is resected until the sinoaortic junction. When reaching 20ºC (nasopharyngeal temperature), ECC is stopped, clamping the bovine trunk to continue with the unilateral anterograde cerebral perfusion (ACP), removing the rest of the previous trans-section aneurysm of the left subclavian artery until the onset of the descending aorta where the mural thrombi described in the CAT were visualized. At this level, a 28 mm woven impregnated arterial prosthesis was sutured on aTeflon felt band with prolene 3/0 suture. The graft is clamped and with a cannula inserted at this level, ECC is restarted and re-warming is started. The duration of the circulatory arrest was 26 minutes. Next, the proximal anastomosis of the graft to the sino-aortic junction was made. Once this procedure was completed, debranching is carried out by suturing a graft of 16 mm to the bovine trunk and the very proximal graft of the aorta, with the left subclavian artery being re-implanted later, by interposition of an 8 mm graft that is anastomosed to the 16 mm graft (Figure 4). The pump is left after 175 minutes of ECC and 149 minutes of aortic clamping.

Figure 2. Surgical aspect of the aneurysm of the ascending aorta and arch

 

Figure 3. Dissection and isolation of the supra-aortic vessels. The anatomical variety called “bovine arch” (left carotid artery emerging from the brachiocephalic trunk) is clearly seen. AscAo: Ascending aorta; BT: Bovine trunk; LCA: Left carotid artery; LSA: Left subclavian artery.

 

Figure 4. Surgical aspect after completing the replacement of the ascending aorta and arch and debranching conducted on the supra-aortic vessels

 

The morning after, the patient had to undergo surgery again because of intrapericardial hematoma that caused an acute obstruction syndrome of the superior vena cava (SVC).

The post-operative period elapsed with her being hemodynamically stable and compensated, in mechanical respiratory assistance (MRA) until the 7th day by respiratory dysfunction.

On May 11, 2012, tomographic control is made before the implant of the endoprosthesis that does not show elements that would contraindicate the procedure.

On May 15, 2012, 21 days after the surgery, in the hemodynamic lab before the endovascular procedure, a spinal catheter is placed for pressure monitoring and possible drainage of cephalorachidian fluid (CRF). Under general anesthesia, the peripheral vascular surgery team gets access to the right external iliac artery suturing an 8 mm graft through which the procedure is made, given the small caliber of the common femoral artery. The aortogram of control with a graded pigtail catheter shows surgical prosthesis and arch of regular edges with a good image and a proper adjustment in proximal and distal anastomosis, with marked angulation in the descending aorta junction. The graft from the proximal ascending aorta to the bovine arch and the left subclavian artery showed a proper angiographic image with excellent adjustment of the diameters in the distal anastomosis.

The descending aorta with the already described great aneurysm extended until the origin of the celiac trunk. After the thorough visualization of the anatomical repairs and the corresponding measurements, the first of the 3 endoprosthesis was implanted (Valian Thoracic of Medtronic) of 34 mm of diameter by 150 mm of length, overlapping the proximal end with the distal end of the surgical prosthesis, deploying it later to the rest of the aortic arch (Figure 5).

Figure 5. Deployment of the 1st stent in the aortic arch

 

Later 2 other endoprosthesis were implanted of 38 mm of diameter by 200 mm of length and 40 mm of diameter by 150 mm of length respectively, covering all the trajectory of the descending artery and the start of the abdominal aorta until the origin of the first visceral branch, identified with a right coronary artery catheter at its origin.

Taking into account the marked angle in the distal end of the surgical prosthesis and to facilitate the passage of the devices, Amplatz super stiff guidewires (Boston scientific) and lunderquist extra stiff guidewireswere used. The final chest aortogram showed exclusion of the aneurysm and a good prosthesis apposition (Figure 6). There were no leaks of any type observed.

Figure 6. Post-implant control aortogram

 

The patient was discharged on June 1, 2012 for a control in an external office.

In October, infection of superficial sternal wound is drained, due to Staphylococcus epidermidis, with a good evolution.

In November, control is requested with multislice CAT to assess the result of the treatment, that by its 3D reconstructions (Figures 7 and 8) shows the successful result of the procedure in its 2 stages, with proper apposition of the endoprosthesis and no leaks at its level. Figure 9 compares the anatomy of the sector treated before and after repair.

The patient will continue under clinical and imaging control to continue with the evolution of the treated and untreated sectors of the aorta.

Figure 7. 3D reconstruction showing the result of the treatment. The areas treated with grafts and the debranching of the area treated with stent grafts are seen

 

Figure 8. Postero-lateral view of the 3D reconstruction, showing the surgical repair of the proximal aorta and the debranching and the rest of the endovascular repair

 

Figure 9. Anatomy of the sector treated before and after the repair

 


DISCUSSION
The case reported presented two significant challenges: 1) the extension of the aortic disease, and 2) the imminence of a complication at the level of the proximal descending aorta, since the patient was symptomatic.

The first forces a combined treatment in 2 stages to, only in the second stage approach the descending aorta, the origin of the symptoms. The interval between both stages usually requires days or weeks, a lapse in which aorta rupture may unfortunately, occur, with the less of the patient, a situation that in some series has been reported in up to 75% of the cases, especially when the whole procedure was surgical [4].

In an attempt to prevent this, Safi et al [4], published in 2006 the first case of hybrid treatment in a single stage, with a favorable result, thus showing the feasibility of the procedure.

Our team opted for the approach in 2 stages during the same hospitalization, because we considered it more cautious and safe, according to our experience inthis type of pathology.

During the surgical procedure, we opted for debranching of the supra-aortic vessels and not using the simple, or frozen elephant trunk technique, due to familiarity with this technique and the presence of bovine arch that facilitated this management. Likewise, and because the graft stents would cover a very extensive length, we decided to revascularize the left subclavian artery and use CRF drainage to prevent medullary ischemia.


CONCLUSIONS
The clinical case presented aneurysmatic disease of the aorta, which involved all the thoracic aorta and a segment of the subdiaphragmatic proximal aorta, shows the successful treatment by a combined or “hybrid” procedure in two stages (surgical and endovascular). This type of approach allows tackling the comprehensive treatment of a pathology of the aorta that is so extensive, with better prognostic prospects, when considering morbi-mortality, in comparison with the surgical treatment in one or two treatments as single option.

The favorable evolution of the patient supported in this case, the decision adopted by our team for her treatment.

 

REFERENCES

  1. Wong CH, Wyatt MG, Jackson R, et al. A dual strategic approach to mega-aortic aneurysms. Eur J Cardiothorac Surg 2001; 19: 528-530.
  2. Borst HG, Frank G, Schaps D. Treatment of extensive aortic aneurysms by a new multiple-stage approach. J Thorac Cardiovasc Surg 1988; 95: 11-13.
  3. Coselli JS, Le Maire SA, Miller III CC, et al. Mortality and paraplegia after thoracoabdominal aortic aneurysm repair: a risk factor analysis. Ann Thorac Surg 2000; 69: 409-414.
  4. Alí A, Estrera AL, Porat EE, et al. The hybrid elephant trunk procedure: a single-stage repair of an ascending, arch and descending thoracic aortic aneurysm. J Vascular Surg 2006; 44: 404-407.

 

 

Publication: June 2013

 
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