Off-Pump Aortic Arch Debranching Via Upper Ministernotomy

Aortic arch disease can be addressed in different ways, including debranching followed by endograft coverage. A 72-year-old male patient presented with a 5.7 cm aortic aneurysm abutting the origin of the left subclavian artery. He underwent proximal aortic arch debranching, which included the innominate and left common carotid arteries, followed by coil embolization of the proximal left subclavian artery, endograft coverage of the arch and proximal descending thoracic aorta, and a left carotid-subclavian bypass.  

The technical aspects of the proximal aortic arch debranching are as follows: An upper ministernotomy was performed, and the innominate vein was isolated on a vessel loop. Both the innominate artery and left common carotid artery were isolated. Pericardial marsupialization was performed, and heparin (10,000 units) was administered. A Satinski clamp was applied to the ascending aorta with low blood pressure. An aortotomy was performed with an 11-blade and then enlarged with punches. The proximal end of the branched synthetic graft was sewn to the aorta using 4-0 Prolene. After the clamp was released, the graft was flushed. The innominate artery was divided at its base using a stapler, maintaining low blood pressure. The innominate artery was clamped distally, and the staple line was resected. A large limb (12mm) was passed behind the innominate vein, and an anastomosis was made using 5-0 Prolene under high blood pressure. Antegrade and retrograde flushing were performed to deair, then unclamping occurred. The left common carotid artery was divided at its base with low blood pressure. A small limb (8 mm) was passed under the innominate vein. The distal left common carotid artery was clamped, and the staple line was resected. Anastomosis was completed using 5-0 Prolene under high blood pressure. Protamine (50mg) was administered. Radiopaque markers were sewn to the distal end of the proximal aortic anastomosis. A small-bore drain was placed from the right chest wall and routine closure was performed in four layers.  

The same day, the patient was transferred to the hybrid suite, where he underwent coil occlusion of the left subclavian artery, endograft coverage of the arch, and proximal descending thoracic aorta, followed by a left carotid-subclavian bypass. The postoperative course was uneventful. 

This approach to treating aortic arch aneurysms avoids the need for full sternotomy, cardiopulmonary bypass, and circulatory arrest. The optimal interval between proximal arch debranching and the subsequent procedures remains unclear, but in this patient, the procedures were performed on the same day. Close collaboration with endovascular specialists is essential for the success of this approach. 

References

1. Ghazy T, Mashhour A, Schmidt T, et al. Off-Pump Debranching and Thoracic Endovascular Aortic Repair for Aortic Arch Pathology. Innovations. 2015;10(3):163-169. doi:10.1097/imi.0000000000000168

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