Treatment strategies for left subclavian artery during total arch replacement combined with stented elephant trunk implantation

Abstract OBJECTIVES Aortic dissection (AoD) in the presence of an aberrant right subclavian artery (ARSA) is very rare. Clinical experience is limited, and there is no consensus regarding the optimal management strategy. We seek to evaluate the safety and efficacy of the total arch replacement (TAR) and frozen elephant trunk (FET) technique as an approach to AoD in patients with ARSA by retrospectively analysing our single-centre experience. METHODS From 2009 to 2017, we performed TAR + FET for 22 patients with ARSA sustaining AoD (13 acute, 59.1%). The mean age was 46.0 years [standard deviation (SD) 8.3], and 19 patients were male (86.4%). ARSA orifice was dilated in 15 (68.2%) patients, and a Kommerall diverticulum was diagnosed in 13 (59.1%) patients with a mean diameter of 21.8 mm (SD 7.7; range 15–40). Surgery was performed via femoral and right/left carotid cannulation under hypothermic circulatory arrest at 25°C. The ARSA was reconstructed using a separate branched graft. RESULTS ARSA was closed proximally by ligation in 16 (72.7%) patients, direct suture in 4 (18.2%) patients and both in 2 (9.1%) patients. Operative mortality was 13.6% (3/22). Type Ib endoleak occurred in 1 (4.5%) patient at 8 days. Follow-up was complete in 100% at mean 4.2 years (SD 2.0), during which 3 late deaths and 1 reintervention for type II endoleak occurred. Survival was 81.8% and 76.4% at 3 and 5 years, respectively. Freedom from reoperation was 89.2% up to 8 years. In competing risks analysis, the incidence was 22.1% for death, 10.8% for reoperation and 67.1% for event-free survival at 5 years. The false lumen, ARSA orifice and Kommerall diverticulum were obliterated in 100%. Grafts were patent in 100%. No patients experienced cerebral ischaemia and upper extremity claudication. Hypothermic circulatory arrest time (min) was sole predictor for death and aortic reintervention (hazard ratio 1.168, 95% confidence interval 1.011–1.348; P = 0.034). CONCLUSIONS The TAR and FET technique is a safe and efficacious approach to AoD in patients with ARSA. Modifications of routine TAR + FET techniques are essential to successful repair, including femoral and right/left carotid artery cannulation, ligation of ARSA on the right side of the trachea and ARSA reconstruction with a separate graft.

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Total arch replacement using the Gelweave Lupiae graft for an aneurysm arising from Kommerell’s diverticulum with an aberrant left subclavian artery and right-sided aortic arch

Interactive Cardiovascular and Thoracic Surgery ◽

10.1093/icvts/ivy079 ◽

2018 ◽

Vol 27 (2) ◽

pp. 307-309

Author(s):

Yuki Tanaka ◽

Tadashi Kitamura ◽

Yusuke Irisawa ◽

Kagami Miyaji

Keyword(s):

Aortic Arch ◽

Subclavian Artery ◽

Left Subclavian Artery ◽

Total Arch Replacement ◽

Aberrant Left Subclavian Artery ◽

Kommerell’S Diverticulum

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Suturing Fenestration of the Left Subclavian Artery Orifice in Frozen Elephant Trunk Procedure

The Thoracic and Cardiovascular Surgeon ◽

10.1055/s-0040-1715434 ◽

2020 ◽

Author(s):

Mitsumasa Hata ◽

Shinji Wakui ◽

Yusuke Ishii ◽

Rei Hinoura ◽

Susumu Isaka ◽

...

Keyword(s):

Aortic Arch ◽

Stent Graft ◽

Subclavian Artery ◽

Distal Part ◽

Left Subclavian Artery ◽

Frozen Elephant Trunk ◽

Bleeding Events ◽

Elephant Trunk ◽

Novel Technique ◽

Elephant Trunk Procedure

AbstractThe frozen elephant trunk (FET) procedure enables easier replacement of the entire aortic arch because it does not require reaching the distal part of the left subclavian artery (LSCA). However, it requires additional management for reconstruction of the LSCA, which is associated with bleeding events. However, the fenestrated FET technique confers a risk of endoleakage from the fenestration site. We report our unique novel technique in which the proximal side of the hybrid stent graft is cut into V-shape around the subclavian artery and sutured continuously around the orifice of the subclavian artery during aortic stump fixation.

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In-Situ Laser Fenestration of a PTFE Thoracic Aortic Stent Graft for Delayed Left Subclavian Artery Revascularization Following Frozen Elephant Trunk Repair of Type an Aortic Dissection

Annals of Vascular Surgery ◽

10.1016/j.avsg.2018.05.005 ◽

2018 ◽

Vol 51 ◽

pp. 271

Author(s):

Narek Veranyan ◽

Joie Dunn ◽

Michael Bowdish ◽

Fred A. Weaver ◽

Sukgu Han

Keyword(s):

Aortic Dissection ◽

Stent Graft ◽

Subclavian Artery ◽

Left Subclavian Artery ◽

Frozen Elephant Trunk ◽

Elephant Trunk ◽

Aortic Stent Graft

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Total arch replacement through a midsternotomy for a right-sided aortic arch aneurysm with an aberrant left subclavian artery

Journal of Thoracic and Cardiovascular Surgery ◽

10.1016/j.jtcvs.2006.08.033 ◽

2006 ◽

Vol 132 (6) ◽

pp. 1473-1475 ◽

Cited By ~ 8

Author(s):

Masashi Kai ◽

Hitoshi Okabayashi ◽

Yoshiharu Soga ◽

Michiya Hanyu ◽

Takuya Nomoto ◽

...

Keyword(s):

Aortic Arch ◽

Subclavian Artery ◽

Left Subclavian Artery ◽

Aortic Arch Aneurysm ◽

Total Arch Replacement ◽

Aberrant Left Subclavian Artery ◽

Arch Aneurysm

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Use of On-Site Digital Subtraction Angiography for Left Subclavian Artery Management During Hybrid Aortic Arch Repair in DeBakey I Dissection

Journal of Endovascular Therapy ◽

10.1177/15266028211068759 ◽

2022 ◽

pp. 152660282110687

Author(s):

Peter-Lukas Haldenwang ◽

Mahmoud Elghannam ◽

Dirk Buchwald ◽

Justus Strauch

Keyword(s):

Digital Subtraction Angiography ◽

Subclavian Artery ◽

Cerebral Perfusion ◽

Left Subclavian Artery ◽

Circulatory Arrest ◽

False Lumen ◽

Distal Anastomosis ◽

Digital Subtraction ◽

Selective Cerebral Perfusion ◽

Elephant Trunk

Purpose: A hybrid aortic repair using the frozen elephant trunk (FET) technique with an open distal anastomosis in zone 2 and debranching of the left subclavian artery (LSA) has been demonstrated to be favorable and safe. Although a transposition of the LSA reduces the risk of cerebellar or medullar ischemia, this may be challenging in difficult LSA anatomies. Case Report: We present the case of a 61-year old patient with DeBakey I aortic dissection, treated with FET in moderate hypothermic circulatory arrest (26°C) and selective cerebral perfusion using a Thoraflex-Hybrid (Vascutek Terumo) prosthesis anchored in zone 2, with overstenting of the LSA orifice and no additional LSA debranching. Sufficient perfusion of the LSA was proved intraoperatively using LSA backflow analysis during selective cerebral perfusion in combination with on-site digital subtraction angiography (ARTIS Pheno syngo software). No neurologic dysfunction or ischemia occurred in the postoperative course. An angiographic computed tomography revealed physiologic LSA perfusion, with subsequent thrombotic occlusion of the false lumen in the proximal descending aorta after 7 days. Conclusion: Using an angiography-guided management in patients with complex DeBakey I dissection and difficult anatomy may simplify a proximalization of the distal anastomosis in zone 2 for FET, even without an additional LSA debranching.

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