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Hybrid Aortic Type I Dissection Repair

Tuesday, March 5, 2019

Clusa NM, Camporrotondo M, Navia D, et al.. Hybrid Aortic Type I Dissection Repair. March 2019. doi:10.25373/ctsnet.7771187.

In this video, the authors show a two-stage hybrid treatment strategy for DeBakey type I aortic dissection. The patient was a 70-year-old man who arrived from another institution with a diagnosis of chronic aortic dissection type I of the DeBakey classification.

The computed tomography (CT) scan showed an aortic wall hematoma in the ascending aorta and aortic arch with an intimal flap that reached both femoral arteries, with no compromise of the mesenteric artery or celiac trunk. The renal arteries were affected by the dissection but without flow alterations or renal failure.

The first stage of this hybrid strategy was the ascending aorta and arch replacement, using axillary cannulation for unilateral cerebral perfusion. After sternotomy was performed, the authors found firm adhesions due to the chronicity of the aortic syndrome that made surgical dissection of the ascending aorta and arch really demanding. After supra-aortic vessels were identified and individualized, cross-clamp of the aorta was achieved and the ascending aorta incised. A huge chronic wall hematoma was found. The ascending aorta aneurysm was resected and the aortic root was prepared for proximal suprasinus aortic anastomosis and aortic valve resuspension.

When the patient’s body temperature reached 25°C (moderate hypothermia), the supra-aortic vessels were clamped, aortic cross-clamp was removed, and distal aorta circulatory arrest with anterograde unilateral cerebral perfusion was begun. At this moment, the authors continued with aortic arch resection, brachiocephalic trunk and left carotid artery transection, and fenestration of the distal intimal dissection flap. A four-branched graft was prepared and invaginated for arch replacement with an elephant trunk technique. The graft was placed into the descending aorta and the distal anastomosis was done with 4-0 polypropylene continuous suture. The graft was then retracted backwards and the authors used one of the branches to connect the arterial line, allowing the distal aorta perfusion through the graft, with selective clamping of the other branches.

The authors’ next step was the left carotid artery anastomosis to the second branch of the prosthesis. After this, they decided to complete the proximal aortic anastomosis and thus they were able to reperfuse the coronary arteries and reduce cardiac ischemic time. Afterwards, the brachiocephalic trunk was anastomosed to the first branch of the graft. The left subclavian artery was left in the distal native aorta, and the authors decided not to reimplant it in the prosthesis due to the technical difficulties given by the deep anatomical disposition of it and in order to reduce surgery time. To ensure that there would not be ischemic complications of the left arm, the authors measured the blood pressure in the left radial artery and compared it to the blood pressure in the femoral artery, and they were similar. There were no ischemic complications of the left arm in the postoperative period.

The patient’s postoperative course required two days in the intensive care unit, blood transfusions, and inotropic support in the first hours. There were no postoperative major complications, and the patient was discharged on the seventh day after the procedure.

The second stage was carried out three months after the first surgery at the same institution. A thoracic endovascular graft was placed in the distal elephant trunk and descending aorta, excluding the dissection flap. Also, a plug Amplatzer was placed in the left subclavian artery ostium. The postoperative course was uneventful. There were no endoleaks or ischemic complications.

A two-year follow-up of the patient’s evolution was uneventful, with a great life quality.

Suggested Reading

  1. Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using “elephant trunk” prosthesis. Thorac Cardiovasc Surg. 1983;31(1):37-40.
  2. Schepens MA, Dossche KM, Morshuis WJ, van den Barselaar PJ, Heijmen RH, Vermeulen FE. The elephant trunk technique: operative results in 100 consecutive patients. Eur J Cardiothorac Surg. 2002;21(2):276-281.
  3. Kazui T, Washiyama N, Muhammad BA, et al. Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion. Ann Thorac Surg. 2000;70(1):3-8.
  4. Shrestha M, Martens A, Krüger H, et al. Total aortic arch replacement with the elephant trunk technique: single-centre 30-year results. Eur J Cardiothorac Surg. 2014;45(2):289-295.
  5. Zhang MH, Du X, Guo W, Liu XP, Jia X, Ge YY. Early and midterm outcomes of thoracic endovascular aortic repair (TEVAR) for acute and chronic complicated type B aortic dissection. Medicine(Baltimore). 2017;96(28):e7183.
  6. Chen Y, Zhang S, Liu L, Lu Q, Zhang T, Jing Z. Retrograde type A aortic dissection after thoracic endovascular aortic repair: a systematic review and meta-analysis. J Am Heart Assoc. 2017;6(9):e004649.


Nestor and Manuel, the video is excellent as usual, great case! Congrats!. Just a couple of questions: 1. Did you think at the very beginning to approach this case in a single-stage technique using an E-vita device rather than in a two-stage technique?. 2. Could the right axillary artery be cannulated with an EOPA cannula and avoid to place a Dacron graft? Or, did you believe that the arm ischemia could it be too long? 3. Regarding the left subclavian artery, it wasn´t possible to approach it through a left subclavian incision and perform an end-to-side anastomosis with the remaining dacron branch? Or the anatomy was really challenging? Thank you and congratulations again for this well-explained and detailed video!
Thank you very much for your comment German. In response to your questions: 1- In cases like this we always consider using a single stage aproach with a hybrid stented graft such as E-vita, but those grafts are more expensive and most of the times the health insurance company won´t authorize them. In this particular case patient´s health insurance did not accept to pay the cost of E-Vita graft, but we think this was a great case for single stage hybrid treatment. We think Two Stage Hybrid treatment is safe and reproducible technique for centers with the same limitation to access to this prothesis. 2- We recognize that subclavian direct cannulation with Seldinger technique using a EOPA cannula is a valid option, in fact its simpler and fastest, but we use a N°8 Dacron prothesis as routine, mainly to avoid ischemic complcations of the right arm. Also we prefer this technique in aortic disecctions to ensure blood flow in the true light of the vessel that might be compromised. 3- We decided not to reimplant or bypass the left subclavian artery in this particular case in order to reduce surgery time, but it is not our routine, we usually reimplant the LSA with a branch of the graft. Nevertheless, not reimplanting the LSA is a valid option reported in literature. Our plan in this case was to perform an extraanatomical by pass only in the presence of left arm ischemia, wich did not occur, so another intervention was not required. Thanks again for your comments and your contribution!

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