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

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.

scholarly journals Total arch replacement and frozen elephant trunk for aortic dissection in aberrant right subclavian artery

2020 ◽  
Vol 58 (1) ◽  
pp. 104-111 ◽  
Author(s):  
Jian-Rong Li ◽  
Wei-Guo Ma ◽  
Yu Chen ◽  
Jun-Ming Zhu ◽  
Jun Zheng ◽  
...  
Keyword(s):  
Aortic Dissection ◽  
Subclavian Artery ◽  
Circulatory Arrest ◽  
False Lumen ◽  
Hypothermic Circulatory Arrest ◽  
Total Arch Replacement ◽  
Aberrant Right Subclavian Artery ◽  
Frozen Elephant Trunk ◽  
Elephant Trunk ◽  
Artery Cannulation

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.

Delivery of antegrade cerebral perfusion during descending aortic reconstruction: a case report

Perfusion ◽  
2008 ◽  
Vol 23 (2) ◽  
pp. 135-137 ◽  
Author(s):  
C Osborne-Bossert ◽  
D Fitzgerald ◽  
A Speir ◽  
J St Onge
Keyword(s):  
Aortic Aneurysm ◽  
Subclavian Artery ◽  
Cerebral Perfusion ◽  
Left Subclavian Artery ◽  
Circulatory Arrest ◽  
Hypothermic Circulatory Arrest ◽  
Neurological Deficits ◽  
Descending Aortic Aneurysm ◽  
Selective Antegrade Cerebral Perfusion ◽  
Antegrade Cerebral Perfusion

Antegrade cerebral perfusion (ACP) has been demonstrated to be a safe and effective method of providing adequate protection to the brain during hypothermic circulatory arrest. By improving oxygen delivery to the cerebral capillaries, users of this technique have reported fewer temporary neurological deficits in postoperative periods, even after prolonged periods of circulatory arrest. Furthermore, ACP may be delivered with little alteration to the cardiopulmonary bypass (CPB) circuit. Surgical correction of a descending aortic aneurysm can provide a challenge when the left subclavian artery is involved. A period of hypothermic circulatory arrest is required to complete the proximal anastamosis of the graft. Access to the cerebral vessels for selective cerebral perfusion is limited during a left thoracotomy approach. A 54-year-old female presented with a computerized tomography (CT) scan of a descending aortic aneurysm, originating at the base of the left subclavian artery. Surgical intervention using CPB via femoral-femoral cannulation was employed. The patient was systemically cooled to 22°C. Selective antegrade cerebral perfusion was administered via cannulation of the left common carotid artery. Antegrade cerebral perfusion lasted 19 minutes, with improved transcranial oximetry readings. The patient was successfully weaned from CPB. The patient was discharged on postoperative day nine with no evident suquelae. It is believed that the application of ACP in this procedure further improved patient outcome.

scholarly journals Modified Isolated Cerebral Perfusion Technique for Prevention of Stroke With Aortic Arch Replacement

2021 ◽  
Author(s):  
Yasumi Maze ◽  
Toshiya Tokui ◽  
Masahiko Murakami ◽  
Teruhisa Kawaguchi ◽  
Ryosai Inoue ◽  
...  
Keyword(s):  
Aortic Arch ◽  
Subclavian Artery ◽  
Cerebral Perfusion ◽  
Left Subclavian Artery ◽  
Axillary Artery ◽  
Selective Cerebral Perfusion ◽  
Aortic Arch Replacement ◽  
Artery Cannulation ◽  
Postoperative Stroke ◽  
Artificial Graft

Abstract In aortic arch replacement, an isolated cerebral perfusion method has been reported in additional to axillary artery cannulation to prevent postoperative stroke. We have made changes to this method. In other words, we devised a method to reduce cerebral embolism by performing selective cerebral perfusion via an artificial graft anastomosed to the left common carotid artery and the left subclavian artery. This method was performed in 7 cases, and all patients were discharged alive without any neurological disorders. In the surgical procedure of the aortic arch, sufficient care must be taken in the manipulation around the brachiocephalic artery and the left subclavian artery. Our method can avoid reinsertion due to desorption of the cerebral perfusion cannula and can be expected to prevent postoperative stroke.

Open Distal Anastomosis Technique for Ascending Aortic Aneurysm Repair without Cerebral Perfusion

2015 ◽  
Vol 18 (4) ◽  
pp. 124
Author(s):  
Mehmet Kaplan ◽  
Bahar Temur ◽  
Tolga Can ◽  
Gunseli Abay ◽  
Adlan Olsun ◽  
...  
Keyword(s):  
Aortic Aneurysm ◽  
Cerebral Perfusion ◽  
Circulatory Arrest ◽  
Deep Hypothermic Circulatory Arrest ◽  
Hypothermic Circulatory Arrest ◽  
Distal Anastomosis ◽  
Ascending Aortic Aneurysm ◽  
Aortic Aneurysm Surgery ◽  
Aneurysm Repair ◽  
Aortic Aneurysm Repair

<p><strong>Background</strong><strong>: </strong>This study aimed to report the outcomes of patients who underwent proximal thoracic aortic aneurysm surgery with open distal anastomosis technique but without cerebral perfusion, instead under deep hypothermic circulatory arrest.</p><p><strong>Methods: </strong>Thirty patients (21 male, 9 female) who underwent ascending aortic aneurysm repair with open distal anastomosis technique were included. The average age was 60.2±11.7 years. Operations were performed under deep hypothermic circulatory arrest and the cannulation for cardiopulmonary bypass was first done over the aneurysmatic segment and then moved over the graft. Intraoperative and early postoperative mortality and morbidity outcomes were reported.</p><p><strong>Results</strong><strong>: </strong>Average duration of cardiopulmonary bypass and cross-clamps were 210.8±43 and 154.9±35.4 minutes, respectively. Average duration of total circulatory arrest was 25.2±2.4 minutes. There was one hospital death (3.3%) due to chronic obstructive pulmonary disease at postoperative day 22. No neurological dysfunction was observed during the postoperative period.<strong></strong></p><p><strong>Conclusion: </strong>These results demonstrate that open distal anastomosis under less than 30 minutes of deep hypothermic circulatory arrest without antegrade or retrograde cerebral perfusion and cannulation of the aneurysmatic segment is a safe and reliable procedure in patients undergoing proximal thoracic aortic aneurysm surgery.</p><p> </p>

Cerebral physiology and outcome after hypothermic circulatory arrest followed by selective cerebral perfusion

2003 ◽  
Vol 76 (6) ◽  
pp. 1972-1981 ◽  
Author(s):  
Justus T Strauch ◽  
David Spielvogel ◽  
Peter L Haldenwang ◽  
Alexander Lauten ◽  
Ning Zhang ◽  
...  
Keyword(s):  
Cerebral Perfusion ◽  
Circulatory Arrest ◽  
Hypothermic Circulatory Arrest ◽  
Selective Cerebral Perfusion ◽  
Cerebral Physiology

Intraoperative angiography for visceral arteries originating from false lumen

2021 ◽  
pp. 021849232110414
Author(s):  
Shintaro Takago ◽  
Satoru Nishida ◽  
Yukihiro Noda ◽  
Yu Nosaka ◽  
Ryo Yamamura ◽  
...  
Keyword(s):  
Aortic Dissection ◽  
Aortic Arch ◽  
Circulatory Arrest ◽  
False Lumen ◽  
External Iliac Artery ◽  
Acute Type ◽  
Elephant Trunk ◽  
Intraoperative Angiography ◽  
Visceral Arteries ◽  
Enhanced Computed Tomography

A 70-year-old man had an acute type B aortic dissection 9 years before his admission. The last enhanced computed tomography that was performed revealed an aneurysm that extended from the ascending aorta to the aortic arch, associated with a chronic aortic dissection, which extended from the aortic arch to the left external iliac artery. His visceral arteries originated from the false lumen. We performed a total arch replacement with a frozen elephant trunk in the hybrid operating room. Immediately after the circulatory arrest termination, using intraoperative angiography, we verified that the blood supply to the visceral arteries was patent.

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