Hybrid Repair with Reversed Sequence Supra-aortic Debranching in Ruptured Arch Aneurysm

Aortic arch pathology in a high-risk patient in whom the resternotomy approach is unfeasible due to treated mediastinitis after ascending aortic replacement presents a unique challenge for hybrid arch repair (HAR) because of the need for supra-aortic debranching from unusual inflow sites other than the ascending aorta. This report describes a “reversed sequence” extra-anatomical supra-aortic debranching procedure as a salvage technique performed to enable HAR. An 83-year-old woman with a history of ascending aortic replacement for type A aortic dissection, mediastinitis complicated by sternal osteomyelitis, and a chest wall reconstructed with a rectus abdominis myocutaneous flap presented with chest pain because of a contained dissecting arch aneurysm rupture. The patient underwent supra-aortic debranching from the bilateral common femoral arteries and thoracic endovascular aortic repair to the ascending aorta under cerebral near-infrared spectroscopy (NIRS) monitoring. Completion imaging by angiography demonstrated successful exclusion of the ruptured aneurysm. The regional cerebral oxygen saturation level, monitored by NIRS, did not change markedly during surgery. The patient was neurologically intact with adequate cerebral blood flow assessed postoperatively by 123I-IMP single photon emission computed tomography. Total debranching of the supra-aortic vessels from the common femoral artery for inflow is feasible and provides adequate cerebral perfusion. This procedure may offer an alternative treatment option in patients with complex conditions involving aortic arch pathology.

Physician-Modified Endograft With Triple Inner Branches for Extensive Aortic Arch Aneurysm

Purpose: The purpose of this case report was to demonstrate the feasibility of a physician-modified endograft (PMEG) with 3 inner branches for extensive aortic arch aneurysm. Case Report: A 69-year-old male presented with extensive aortic arch aneurysm involving all supra-aortic vessels. An Ankura thoracic stent graft was modified with 3 inner branches fashioned of Viabahn endoprostheses. The procedure was technically successful, and the patient was discharged with no complications. Conclusion: This back-table modification of the off-the-shelf endograft is an especially attractive option for complex arch pathologies with urgency and deemed too high risk for reopen surgery.

Total Aortic Arch Replacement: Case Report of the first successful total arch replacement in Nepal and Review of contemporary techniques in arch surgery

Aortic arch replacement is formidable cardiac surgery that is fraught with complications like brain injury, coagulopathy along with high mortality. Over the past several years, various techniques like deep hypothermic circulatory arrest, retrograde cerebral perfusion, and selective antegrade cerebral perfusion along with branched graft techniques have been developed with better early outcomes. We share our experience of successful replacement of ascending and total aortic arch in a 60 years old female, who presented with ascending and aortic arch aneurysm.

Abstract 1122‐000158: Flow Diversion of Cerebral Aneurysms via Direct Carotid Artery Cutdown: A Case Series

Introduction : Flow diversion (FD) of the cerebral aneurysms (CA) are performed either by trans femoral or transradial approach. Safety and feasibility of an alternative option such as direct Carotid artery Cutdown (DCAC) and FD for the treatment of the CA in a situation when tradition approaches are not feasible is not well described. Methods : Retrospective review. Results : First patient; 67 years old man with history of hypertension, hyperlipidemia, smoking, and stenting of the aortic arch aneurysm was diagnosed with symptomatic bilateral ICA DSA buy a CT angiography. Right ICA DSA was in multi‐level extending from cervical carotid artery to the skull base measured 19 × 15 × 20 mm and the left was 16 × 9 × 22 mm. Considering the severity of the disease and the presence of symptoms, planned for a DCAC by vascular surgeon followed by FD by neurovascular surgeon (NES) in a staged fashion. A 6F sheath was placed from right common carotid artery (CCA) to right ICA by a vascular surgeon. A CAT5 catheter was navigated to the ICA beyond DSA. FD was achieved using Surpass streamline measuring 4 × 50 mm x2 and a 5 × 40 mm. The DCAC site was sutured by vascular surgeon and patient was extubated. Using similar techniques, Left‐sided DPA was repaired using 5 × 50 mm surpass streamline flow diverter in 3 months. Second patient; 75 years old women’s let ICA opththalmic (ICA‐O) aneurysm grown from 8 mm to 12 mm with headaches. TF and TR approaches failed, underwent DCAC and FD with pipeline flex (PF) 5 × 30 mm using phenom plus and phenom XT27 microcatheter. Third patient; 65 years old women with LICA‐0 9 mm symptomatic aneurysm with occlusions femoral and radial arteries due to smoking underwent FD with PF of 4 × 30 mm. There were no clinical events, first patient’s right ICA radiographic dissection was repaired by VS prior to extubation. Patients were discharged home in 48 hours with NIHSS 0 and achieved baseline mRS. Patients were continued full antiplatelets for six months followed by an 81 mg baby aspirin and 75 mg of clopidogrel. Follow‐up MR angiogram demonstrate complete obligations of the aneurysms without stenosis. Conclusions : Our case series demonstrate that DCAC for the FD of the intracranial aneurysm is feasible and safe when performed carefully and in coordination with a multidisciplinary team. Further studies are required.

Clinical case of hybrid treatment for a saccular aneurysm of the aortic arch

The article presents a clinical case of a staged hybrid treatment for an aortic arch aneurysm in patient who previously underwent coronary artery bypass grafting and exoplasty of the ascending aorta. Possible alternative treatment options for this pathology are reviewed, and the features of surgical and endovascular treatment are also described.

One-Stage Hybrid Total Aortic Arch and Descending Thoracic Aortic Repair is a Safe and Secure Procedure With Less Postoperative Complications for Extended Aortic Arch Aneurysms

Purpose Hybrid aortic arch repair (HAR) has been implemented for extended aortic arch and descending thoracic aortic disease since 2012 in our institution. This study aimed to estimate the early and mid-term efficacy and safety of HAR. Materials and Methods From 2007 to 2019, 56 patients underwent HAR for extended aortic arch disease, and 75 patients underwent total arch replacement (TAR) for arch-limited disease. HAR comprises 3 procedures: replacement of the aorta, reconstruction of all arch vessels, and thoracic endovascular aortic repair (TEVAR) from zone 0 to the descending aorta after cardiopulmonary bypass is off in 1 stage. The type II-1 HAR procedure, in which the ascending aorta and aortic arch distal to the brachiocephalic artery are replaced, was the most frequently selected procedure (40/56 patients). The outcomes of the type II-1 HAR procedure were compared with those of TAR using the Cox regression analysis. Results The median follow-up period was 36 months. In HAR, the operative mortality, in-hospital mortality, and postoperative permanent neurological deficits were not observed. The paraplegia rate was 1.8%. TEVAR-related complications occurred in 3 patients. Among the patients with non-ruptured atherosclerotic aortic arch aneurysm (31 type II-1 HAR patients and 36 TAR patients, the postoperative respiratory support time in those who underwent type II-1 HAR was quicker than in those who underwent TAR (p<0.01). The rate of 6 year freedom from all-cause death in type II-1 HAR (83.1%) was numerically higher than that in TAR (74.7%), and the rate of 6 year freedom from surgery-related complications in type II-1 HAR (90.3%) was numerically lower than that in TAR (96.9%) due to the occurrence of TEVAR-related complications, and the rate of 6 year freedom from reintervention to the descending thoracic aorta in type II-1 HAR (100%) seemed to be better than that in TAR (83.7%). However, Cox regression analysis did not reveal any statistical difference between the 2 procedures. Conclusions HAR, especially the type II-1 procedure, can treat extended aortic arch disease with acceptable survival outcomes. The development of TEVAR technology will further improve the outcomes of HAR in the future.

A Rare Case of an Ascending Aorta and Aortic Arch Aneurysm with an Aberrant Right Common Carotid Artery

Ascending aortic aneurysms are asymptomatic and are usually discovered as an incidental finding on chest imaging. However, larger aneurysms can present with symptoms resulting from compression of surrounding structures including the trachea, bronchi, and the esophagus which can result in hoarseness, cough chest pain or back pain. The presence of an aortic arch anomaly, specifically an aberrant right common carotid artery, in a background of an aortic arch aneurysm is extremely rare with a worldwide incidence of <1%. They are usually asymptomatic but can result to catastrophic life threatening events and pose significant challenges to surgical or endovascular treatment. This is a case of a 63-year old Filipino male who presented with a sudden onset of dull back pain radiating to the left anterior chest. Workup revealed an ascending and aortic arch aneurysm with an aberrant right common carotid artery arising directly from the transverse aorta. Surgical aortic arch debranching was done to repair the aberrant vessels prior to Thoracic Endovascular Aortic Repair (TEVAR) wherein a custom-made Thoracic Valiant graft was deployed on the aneurysm. The patient was discharged on the 4th day after TEVAR without any complaints of dyspnea, back pain nor chest pain with no neurologic and visceral organ dysfunction. This case has emphasized that knowledge on the anatomy of the aortic arch is imperative in planning out thoracic surgery and endovascular interventions especially on rare anatomic anomalies such as seen in this case. Keywords aortic aneurysm, aberrant right common carotid artery, TEVAR