Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 187-189

Distalization of left subclavian artery for cerebral revascularization during hybrid repair of complex and contained rupture of aortic arch aneurysm


1 Department of CVTS, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
2 Head of Vascular Surgery, SUT Hospital, Thiruvananthapuram, Kerala, India

Date of Web Publication29-Aug-2019

Correspondence Address:
Prof. Unnikrishnan Madathipat
Head of Vascular Surgery, SUT Hospital, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_5_19

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  Abstract 


A ruptured aortic arch aneurysm is imminently fatal unless expeditiously intervened. Hybrid thoracic endovascular aneurysm repair has revolutionized the therapeutic paradigm, in a complex clinical setting, in particular, compared to demanding and particularly riskier open reconstruction with its attendant cardiac and neurological sequelae. Herein, we describe a 52-year-old male who presented with a ruptured aortic arch aneurysm and concomitant innominate artery aneurysm with occluded left common carotid artery (CCA). Computed tomography (CT) aortogram visualized large retrosternal hematoma precluding sternotomy without circulatory arrest and distal end of aneurysm abutting ostium of theleft subclavian artery (LSA). Therefore, staged reimplantation of LSA to descending thoracic aorta (DTA) and extra-anatomic LSA to right CCA bypass were performed through posterolateral thoracotomy followed by Zone 0 deployment of the aortic stent graft. The patient keeps good health and remains asymptomatic at 2 years of follow-up. Repeated CT aortogram done immediate postoperatively and at 13 months showed patent graft and no endoleak. Hybrid arch repair by supra-aortic debranching facilitated by distalized LSA on DTA is a viable therapeutic option in patients with complex arch and innominate artery aneurysms that mandate Zone 0 coverage during endovascular aneurysm repair.

Keywords: Aortic arch aneurysm, distalization of the left subclavian artery, hybrid thoracic endovascular aneurysm repair


How to cite this article:
Nair HR, Pitchai S, Kumar V, Madathipat U. Distalization of left subclavian artery for cerebral revascularization during hybrid repair of complex and contained rupture of aortic arch aneurysm. Indian J Vasc Endovasc Surg 2019;6:187-9

How to cite this URL:
Nair HR, Pitchai S, Kumar V, Madathipat U. Distalization of left subclavian artery for cerebral revascularization during hybrid repair of complex and contained rupture of aortic arch aneurysm. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Nov 18];6:187-9. Available from: http://www.indjvascsurg.org/text.asp?2019/6/3/187/265779




  Introduction Top


Gold standard open aortic arch aneurysm surgery in the setting of rupture is associated with substantial mortality and morbidity. Currently, the state-of-the-art endovascular technique is being adopted as an effective alternative treatment of choice world over, particularly in case of elderly, system compromised, and ruptured patients.[1] A purely endovascular technique involves fenestrated stent grafts and branched grafts, which are often limited by availability, cost, and technical expertise. Hybrid endovascular procedure involves open debranching of the supra-aortic trunk branches with exclusion of the aneurysm by an endovascular stent graft.[2] The extent of the aneurysm dictates the complexity of debranching. Hence, for extensive aneurysm, often, a pan arch debranching via midline sternotomy with Zone 0 deployment of the stent graft is mandatory.[3] There are certain situations in which sternotomy may be technically challenging and associated with more complications, such as redo sternotomy. Herein, we present a case of ruptured aortic arch aneurysm along with severe supra-aortic trunk disease which was managed by hybrid thoracic endovascular aneurysm repair (TEVAR). The presence of retrosternal hematoma precluded sternotomy in this patient, and hence, the hybrid procedure was successfully performed by means of the distalized left subclavian artery (LSA) through posterolateral thoracotomy.


  Case Report Top


A 52-year-old hypertensive male was admitted elsewhere with a history of abrupt dyspnea, chest pain, and hemoptysis. Initial chest X-ray showed right-sided pleural effusion requiring intercostal drainage tube that yielded blood. Thereafter, contrast-enhanced CT chest done at the previous hospital showed midaortic arch aneurysm involving the innominate artery with substernal hematoma and occluded extracranial left common carotid artery (CCA) [Figure 1]. The patient was referred to our center after stabilization. On evaluation at our hospital, he was hemodynamically stable. Physical examination showed normal peripheral pulses, except absent left CCA. CT scan confirmed arch aneurysm contiguous with innominate artery aneurysm extending distally up to ostium of the LSA, occluded left CCA, and a large well-circumscribed stable hematoma retrosternally.
Figure 1: (a) Computed tomography angiography axial section showing well outlined retro sternal hematoma (yellow arrow). (b) Oblique sagittal section of computed tomography angiography showing innominate artery and arch aneurysms with contained rupture (red arrow). (c) Three-dimensional reconstruction of computed tomography angiography shows contiguous innominate artery and aortic arch aneurysm. Left common carotid artery is occluded and left vertebral artery has direct origin from the arch (green arrow head)

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The presence of hematoma in the retrosternal region precluded sternotomy, and he was planned for staged descending thoracic aorta (DTA) to LSA and left vertebral artery (VA) bypass followed by LSA to right CCA bypass (cross-neck) and finally Zone 0 deployment of the stent graft. The surgery was performed via left thoracotomy.

LSA was disconnected from the aorta and anastomosed end-to-end with an 8-mm collagen coated polyester graft (Maquet Intergard L) which in turn was anastomosed to mid-DTA (end-to-side). Hence, LSA found inflow from the upper third of DTA well beyond the aortic knuckle. The left VA was bypassed using a 4-mm expanded Polytetrafluoroethylene (ePTFE) graft from the polyester graft (end-to-side). Thereafter, LSA was exposed via supraclavicular approach, and an 8-mm polyester graft was interposed end-to-side from native LSA to the right CCA, which was tunneled deep-to-deep fascia anteriorly. Finally, through transfemoral cutdown, a 38 mm × 107 mm stent graft (Medtronic Valiant Captivia®) was deployed excluding both arch and innominate artery aneurysms [Figure 2]. Through right brachial artery cutdown, a 16-mm Amplatzer® vascular plug was deployed into innominate artery aneurysm to prevent type II endoleak. Check angiogram showed complete exclusion of the aneurysm with patent carotid bypass. The patient had an uneventful postoperative recovery and was discharged in stable condition. At 24 months follow-up, the patient is active, healthy, and back to his job since quite a while. Follow-up chest CT angiogram performed at 13 months showed complete exclusion of the aneurysm and patent bypass graft. The vascular plug had occluded the innominate bifurcation, and right subclavian artery (SCA) was perfused retrogradely through the right VA. Since the patient was asymptomatic with palpable right radial artery pulse, he was managed conservatively with close observation.
Figure 2: Postoperative computed tomography angiography with three-dimensional reconstruction showing: Blue arrow – Polyester graft inflow from upper descending thoracic aorta (end-to-side); Green arrow – Polyester graft for distalizsation; Red arrow – End-to-end anastomosis between graft and detached proximal end of left subclavian artery; White arrow – Polyester graft inflow for cross-neck bypass from the second part of left subclavian artery to right common carotid artery (end-to-side). Both the innominate artery and arch aneurysm are excluded by zone 0 deployment of stent graft. Amplatzer vascular plug and coils deployed into Innominate artery distal to the aneurysm prevented type II endoleak

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  Discussion Top


With endovascular intervention gradually competing, if not replacing, open surgical modality worldwide, especially in the setting of complex aortic arch lesions and high-risk individuals, certain anatomical factors make the procedure even more technically challenging.[1] Like in our index case, the hematoma surrounding the ascending aorta precluded sternotomy which requires the prolonged hypothermic circulatory arrest and extracorporeal circulation right from sternotomy. Furthermore, the hematoma made it impossible to obtain inflow from ascending aorta, like in the conventional Zone 0 hybrid TEVAR.

Retrograde inflow from DTA has been reported in the literature in very rare case reports.[2],[4],[5] The indication in using DTA as an inflow in these reports is either to avoid redo sternotomy or to avoid diseased femoral vessels.[4] The technical point to be noted during such cases is that inflow has to be taken well beyond the distal sealing zone. Even though we staged the procedure, the debranching could be performed on the same day, but the position needed to be changed in between the procedure which is time-consuming. Total endovascular repair with fenestrated or branched stent graft would be fraught with a certain incidence of adverse cerebral events in view of the excessive manipulation required for deploying covered stents to perfuse supra-aortic trunk branches.[6],[7] In our index patient, distalized LSA provided satisfactory inflow for right carotid bypass in the setting of occluded left CCA. Moreover, in a 52-year-old in the setting of only the LSA being healthy (aneurysmal innominate and thrombosed left CCAs), we preferred the durable polyester graft to right CCA, the only available and now lifeline artery for cerebral revascularization, when compared to fenestration. Left CCA occlusion could, most probably, be due to sudden occlusion of carotid artery ostium from luminal thrombus in the aortic arch. It is unlikely that mediastinal hematoma would have led to complete thrombosis since contralateral external carotid artery (ECA) collaterals would have kept distal extracranial arteries on the left side patent.

The concern about the adequacy of postoperative cerebral blood flow after this surgery was addressed by Shimizu et al.[4] They performed duplex scan to look for carotid flow and single positron emission CT to look for global cerebral flow as well as vasoreactivity after administration of acetazolamide in their patient who underwent a similar procedure. Both the results were normal as compared to the controls.


  Conclusion Top


Hybrid arch repair by supra-aortic debranching facilitated by distalized LSA on DTA is a viable (and exclusive one in this context) option in patients with complex aortic arch pathology. To the best of our knowledge, this is the first ever report in published literature, of utilizing distalized LSA, in hybrid TEVAR to repair ruptured arch and innominate aneurysms successfully.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

We place on record their gratitude to the Director of the Institute, Prof. Asha Kishore, for her kind permission to publish our work. We are also grateful to our colleagues in Endovascular team for their extraordinary effort in the management of index case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Murashita T, Matsuda H, Domae K, Iba Y, Tanaka H, Sasaki H, et al. Less invasive surgical treatment for aortic arch aneurysms in high-risk patients: A comparative study of hybrid thoracic endovascular aortic repair and conventional total arch replacement. J Thorac Cardiovasc Surg 2012;143:1007-13.  Back to cited text no. 1
    
2.
Zhou W, Reardon M, Peden EK, Lin PH, Lumsden AB. Hybrid approach to complex thoracic aortic aneurysms in high-risk patients: Surgical challenges and clinical outcomes. J Vasc Surg 2006;44:688-93.  Back to cited text no. 2
    
3.
Bavaria J, Milewski RK, Baker J, Moeller P, Szeto W, Pochettino A, et al. Classic hybrid evolving approach to distal arch aneurysms: Toward the zone zero solution. J Thorac Cardiovasc Surg 2010;140:S77-80.  Back to cited text no. 3
    
4.
Shimizu H, Hachiya T, Yamabe K, Yozu R. Hybrid arch repair including supra-aortic debranching on the descending aorta. Ann Thorac Surg 2011;92:2266-8.  Back to cited text no. 4
    
5.
Iida Y, Ito T, Misumi T, Shimizu H. Total debranching thoracic endovascular aortic arch repair with inflow from the descending thoracic aorta. J Vasc Surg 2016;63:527-8.  Back to cited text no. 5
    
6.
Tsilimparis N, Debus ES, von Kodolitsch Y, Wipper S, Rohlffs F, Detter C, et al. Branched versus fenestrated endografts for endovascular repair of aortic arch lesions. J Vasc Surg 2016;64:592-9.  Back to cited text no. 6
    
7.
Haulon S, Greenberg RK, Spear R, Eagleton M, Abraham C, Lioupis C, et al. Global experience with an inner branched arch endograft. J Thorac Cardiovasc Surg 2014;148:1709-16.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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