Debranching of Aortic Arch Vessels Through a Cervical Approach for Aortic Arch Aneurysm: A Step-by-Step Guide

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In this video, the authors demonstrate the surgical steps of aortic arch vessel debranching through a cervical approach as the first stage in the hybrid treatment for complex aortic arch pathology. 
 
Treatment of thoracic aortic diseases poses a significant surgical challenge. Open surgery is considered the gold standard, which involves a sternotomy accompanied by cardiopulmonary bypass and deep hypothermic arrest. However, these procedures are associated with substantial morbidity and mortality.  

In the current era of endovascular treatment, the management of aortic diseases has been streamlined; however, the involvement of the aortic arch presents a notable exception. In these cases, it is imperative to exclude the arch vessels to maintain uninterrupted antegrade cerebral and upper limb blood flow that the thoracic stent graft would cover, and facilitate an optimal extension of the landing zone. 

Debranching procedures can be categorized into two types: Complete debranching, which entails the reconstruction of all three branches of the aorta, thereby permitting a zone 0 landing; and partial debranching, which allows for the placement of the stent graft in zones 1 or 2, depending on the reconstruction of the left carotid and/or left subclavian arteries.  

In the video, the authors describe the steps for debranching, which enables a zone 1 landing of the thoracic stent graft. 

A 54-year-old man presented with a complaint of hoarseness of voice. Further evaluation revealed a partially thrombosed saccular aneurysm measuring 5 x 4 x 2 cm, situated immediately distal to the left subclavian artery.  

The ascending aorta showed significant thickening and atheromatous changes. The remaining sections of the aorta exhibited normal caliber and thickness, with no signs of dissection flap. A reconstructed image of the aorta illustrated the saccular aneurysm. 

Further, the left common carotid artery was assessed; however, there was no significant stenosis noted in either the right or left systems. Cerebral imaging revealed a normal circle of Willis. 
 
After a comprehensive pre-aesthetic evaluation, he was prepared for surgery. Once the arterial and venous lines were secured, the patient was intubated. He was positioned supine with the neck gently extended.  
 
To avert prolonged cerebral hypoxia, an oximeter was used to measure cerebral oxygenation.  
 
These were the cerebral saturations on both sides before and after intubation. 
 
Sterile drapes were placed to expose the neck, ensuring visibility from the inferior edge of the mandible to just beneath both the clavicles. The skin incision was planned as a straight incision on the right side, following the medial border of the sternocleidomastoid muscle. On the left side, a curvilinear incision was marked, with the vertical limb aligning with the medial border of the left sternocleidomastoid muscle and the lateral extension was 1 cm above the clavicle in the supraclavicular fossa, for a length of 4 cm.  
 
Preemptive analgesia was administered through subcutaneous infiltration of two percent lignocaine. 
 
On the right side, the incision was deepened through the subcutaneous tissue and platysma. The sternocleidomastoid muscle was separated by creating a plane between the investing and pretracheal deep cervical fascia. The carotid sheath was incised, and the right common carotid artery was identified and looped. 
 
The left skin incision was similarly deepened, the carotid sheath opened, and the left common carotid artery was identified and looped. The structures found in the left carotid triangle were noted.  
 
The dissection proceeded by dividing the sternal and clavicular heads of the right sternocleidomastoid muscle, and the left inferior belly of the omohyoid was divided. 

The scalenus pad of fat was excised, and the anterior scalene muscle was cut to enter the supraclavicular fossa. The phrenic nerve was isolated prior to dividing the anterior scalene muscle, which lies on it. 
 
 In the left carotid triangle, the left jugular vein was identified and isolated. The vagus nerve was identified and safeguarded.
 
A retroesophageal tunnel was created from the left neck incision to the right side over the prevertebral fascia, while protecting the recurrent laryngeal nerves and the posterior wall of the esophagus. A marker was left in the tunnel to pass the tube graft later.
 
There were multiple essential nerves in and around this anatomical area that were significant and needed to be preserved. These included the left phrenic nerve, which is medial to the anterior scalenus muscle; the recurrent laryngeal nerve, located in the tracheoesophageal groove; and the inferior trunk of the brachial plexus, positioned superior to the subclavian artery.

As the dissection facilitated adequate exposure of these structures, the patient was heparinized with a dose of 300 units/kg. With an activated clotting time (ACT) greater than 250 seconds, distal and proximal control of the subclavian artery was obtained using vascular clamps, confirmed by the absence of waveform on the left radial arterial line. An arteriotomy of the left subclavian artery (LSCA) was made and extended.
 
An 8 mm Dacron tube graft was used, and one of the ends was beveled. Using a 5-0 monofilament polypropylene suture with a 13 mm, ½ circle, round-bodied needle, the end of the graft was sutured to the side of the artery. However, a 6-0 monofilament prolypropylene with a 13 mm 3/8th circle round-bodied needle could also be used based on the characteristics of the vessel.  

Both distal and proximal clamps were removed, and a clamp was applied to the tube graft to restore flow to the left upper limb.  
 
The tube graft was brought into the carotid triangle under the jugular pad of fat. To maintain the correct alignment of the graft, a black line was always used as a reference marker. Care was taken not to compress the jugular vein. 
 
Proximal control of the left common carotid was taken under oximetric monitoring.  
 
The proximal common carotid artery was divided using an endostapler equipped with a white 45 mm reload.  
 
Before the anastomosis, the graft was navigated through the retroesophageal tunnel into the right carotid triangle. The alignment of the graft was corrected to avoid any bends or twists. 
 
The distal stump of the left carotid artery and the graft were clamped. The graft was incised and extended by 5 mm. The stapled end of the carotid artery was excised and beveled.
 
An end-to-side anastomosis was done using a 5-0 polypropylene suture. The clamps were released and the left carotid supply was established. Then, the proximal right common carotid artery was clamped under cerebral oximetric surveillance. During this phase, cerebral circulation was maintained through the LSCA-graft anastomosis and the graft-left common carotid artery (LCCA) anastomosis.
 
The anastomosis on the right side was prepared by trimming the Dacron graft to an adequate length. A carotid arteriotomy was made and extended. The end of the Dacron graft was sutured to the side of the right common carotid with a 5-0 monofilament polypropylene suture. Once the anastomosis was completed, the clamps were released. At the end of every anastomosis the graft was deaired. 
 
The proximal end of the left subclavian artery was identified. The tube passed beneath the esophagus to enter the left carotid triangle, where it was anastomosed with the distal end of LCCA. It then passed under the jugular pad of fat and the left internal jugular vein (LIJV) to enter the left supraclavicular fossa, finally being anastomosed to the side of the LSCA.  

This series of anastomoses ensured antegrade blood flow from the right common carotid artery to the left common carotid artery and the left subclavian artery. Once hemostasis was assured, both heads of the sternoclavicular heads were approximated. The platysma was sutured with absorbable suture, and then the skin was closed. The patient was then taken up for TEVAR. The fluoroscopy showed the aortic arch with the saccular aneurysm distal to the LSCA. A thoracic stent graft was deployed to cover the aneurysm, which later did not show contrast uptake. 

References

1. Stanger O, Svenson LG, Pepper JR. Surgical management of aortic pathology. Springer, 2019.
2. Kudo, T., Kuratani, T., Shirakawa, Y., Shimamura, K., Kin, K., Sakamoto, T., Shijo, T., Watanabe, Y., Masada, K., Sakaniwa, R., & Sawa, Y. (2022). Effectiveness of Proximal Landing Zones 0, 1, and 2 Hybrid Thoracic Endovascular Aortic Repair: A Single Centre 12 Year Experience. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, 63(3), 410–420. https://doi.org/10.1016/j.ejvs.2021.10.043.
3. Xydas S, Mihos CG, Williams RF, LaPietra A, Mawad M, Wittels SH, Santana O. Hybrid repair of aortic arch aneurysms: a comprehensive review. J Thorac Dis. 2017 Jun;9(Suppl 7):S629-S634. doi: 10.21037/jtd.2017.06.47. PMID: 28740717; PMCID: PMC5505941.
4. Soraya L. Voigt, Muath Bishawi, David Ranney, Babatunde Yerokun, Richard L. McCann, G. Chad Hughes, Outcomes of carotid-subclavian bypass performed in the setting of thoracic endovascular aortic repair, Journal of Vascular Surgery,Volume 69, Issue 3,2019,Pages 701-709,ISSN0741-5214,https://doi.org/10.1016/j.jvs.2018.07
5. Ishimaru S. (2004). Endografting of the aortic arch. Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists, 11 Suppl 2, II62–II71. https://doi.org/10.1177/15266028040110S614/span>
6. Chad Hughes and Andrew Vekstein ,Current state of hybrid solutions for aortic arch aneurysms, Annals of Cardiothoracic Surgery, Volume 10,Number 6,2021,doi: 10.21037/acs-2021-taes-168.

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