Multi-Branched Thoracoabdominal Endovascular Aortic Repair With Branch Access Through a Left Thoracotomy and Descending Thoracic Aortic Conduit: A Novel and Effective Alternative Access

Purpose: To demonstrate an alternative access to perform directional branch catheterization during complex endovascular aortic repair. Technique: Urgent endovascular aortic repair was indicated to treat a symptomatic post dissection thoracoabdominal aneurysm with large infrarenal dilatation with an off-the-shelf t-Branch endograft (Cook Medical, Bloomington, IN, USA). Traditional proximal arterial accesses were not suitable due to a previous aortic arch endograft. A novel approach was performed through a left postero-lateral thoracotomy, isolation of the descending thoracic aorta and anastomosed a polyester graft conduit to allow sheaths passage to the thoracoabdominal aorta with subsequently directional branch catheterization. Conclusion: The descending thoracic aortic conduit technique is an effective alternative for directional branch catheterization and should be considered whenever traditional proximal arterial accesses are not suitable and other endografts configurations not considered due to anatomic limitations.

Describing The Use of Two Hybrid Prostheses in The Staged Surgical Repair of Aortic Dissection

Background-Reconstruction of the thoracoabdominal aorta after dissection (Stanford Type A with extension into descending aorta) has limited surgical options. Described here is a novel technique for the staged surgical repair of the thoracoabdominal aorta after reconstruction of the ascending aorta with aortic arch using a hybrid prosthesis. Case presentation- The thoracoabdominal aorta is accessed via a lateral thoracotomy. After a left-left bypass to perfuse the descending aorta, the proximal end of the prosthesis is anastomosed to the proximal aorta and distal end of the new prosthesis is then inserted into the true lumen of the descending aorta and the stent is deployed. Conclusion-Using this technique, operative time is reduced with accurate reconstructions of the anatomy.

CENTRIFUGAL-FLOW LVAD INFLOW CANNULA POSITION: PREOPERATIVE INFLUENCES AND POSTOPERATIVE OUTCOMES

Background: We previously demonstrated better inflow cannula (IFC) position and reduced pump thrombosis with a centrifugal-flow LVAD (CF-LVAD) compared to an axial-flow device. We hypothesized that implant technique and patient anatomy would affect CF-LVAD IFC positioning and that malposition would impact LV unloading and outcomes. Methods: Pre- and postoperative computed tomography (CT) scans were reviewed for patients with six-month follow-up. Malposition was quantified using angular deviation from an ideal line in two planes. IFC position was compared between conventional sternotomy (CS) and lateral thoracotomy-hemisternotomy (LTHS). The influence of LV end-diastolic dimension (LVEDD), body mass index (BMI), and CT-derived anatomy was determined. LV unloading was assessed by LVAD flow index (FI) and pre- to post-LVAD decrement in mitral regurgitation (MR) and LVEDD. Outcome measures were pump thrombus or stroke (PT/eCVA); 30-day and total heart failure-related readmissions (HFRAs); and survival free of surgery for LVAD dysfunction. Results: One hundred fourteen patients met criteria. Total malposition magnitude was higher for CS than LTHS (p=0.04). Midline-LV apex distance predicted lateral-plane malposition (p=0.04), while apex-LVOT angle predicted both anterior- (p=0.01) and lateral-plane (p=0.04) malposition. Lateral-plane malposition predicted decreased LVAD FI at three (p=0.03) and six (p=0.01) months. Total malposition magnitude predicted increased 30-day HFRAs (p=0.04), while lateral-plane malposition predicted more overall HFRAs (p=0.01). Malposition was not associated with PT/eCVA, changes in MR or LVEDD, or survival free of surgical revision. Conclusions: Patient anatomy and surgical technique were associated with CF-LVAD IFC malposition. In turn, malposition was associated with increased readmissions and decreased LVAD FI.

Posterior Mediastinal Goiter Removal Through Cervical Incision

Intrathoracic goiter when encountered can be treated by thyroidectomy using cervical incision, only occasionally requiring extra cervical approach. We are reporting one such case in a patient with pituitary macroadenoma with extension of the adenomatous goiter into the posterior mediastinum. It was removed through the cervical collar incision using a vessel sealing device. There were no intraoperative and postoperative complications during the procedure. The need for extra cervical incision should be decided on a case-to-case basis to avoid the increased morbidity associated with sternotomy and lateral thoracotomy incision.