Use of custom Dacron branch grafts for “hybrid” aortic debranching during endovascular repair of thoracic and thoracoabdominal aortic aneurysms G. Chad.

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Presentation transcript:

Use of custom Dacron branch grafts for “hybrid” aortic debranching during endovascular repair of thoracic and thoracoabdominal aortic aneurysms G. Chad Hughes, MD, Jeffrey J. Nienaber, MD, Errol L. Bush, MD, Mani A. Daneshmand, MD, Richard L. McCann, MD The Journal of Thoracic and Cardiovascular Surgery Volume 136, Issue 1, Pages 21-28.e6 (July 2008) DOI: 10.1016/j.jtcvs.2008.02.051 Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 A. Preoperative 3-dimensional CT scan reconstruction of a large transverse arch aneurysm. Note adequate proximal landing zone in ascending aorta and distal landing zone in descending thoracic aorta. B. One-month postoperative CT scan from the same patient demonstrating arch debranching graft extending from proximal ascending aorta to left common carotid and innominate arteries. Two stent grafts have been placed, which cover the ostia of the innominate, left common carotid, and left subclavian arteries. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 21-28.e6DOI: (10.1016/j.jtcvs.2008.02.051) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 A. Intraoperative marker arteriogram demonstrating large aortic arch aneurysm and completed proximal ascending aorta to left common carotid and innominate artery bypass. The stent graft introducer sheath has been advanced antegradely into the ascending aorta over a stiff guidewire via the proximal antegrade limb of the arch debranching graft. B. Completion arteriogram after stent graft deployment demonstrating complete exclusion of the aneurysm sac by the stent grafts with no endoleak; arch debranching graft is widely patent. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 21-28.e6DOI: (10.1016/j.jtcvs.2008.02.051) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 One-month postoperative 3-dimensional reconstruction CT scan of a hybrid stented extent II TAAA repair in an 83-year-old woman. Note trifurcated bypass graft extending from left common iliac artery to the mesenteric and renal vessels (A) combined with endovascular aneurysm exclusion via stent grafts extending from the left subclavian artery to just above the aortic bifurcation (B). The Journal of Thoracic and Cardiovascular Surgery 2008 136, 21-28.e6DOI: (10.1016/j.jtcvs.2008.02.051) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Hybrid stented TAAA repair. A, A trifurcated Dacron graft is used to bypass the left renal, superior mesenteric, and right renal arteries end to end. The celiac axis is anastomosed end to side to the distal main body portion of the graft. All aortic side branches are sequentially ligated at their origins (to prevent type II endoleak) and divided just prior to anastomosis to the debranching graft. Thoracic endografts are then deployed to exclude the TAAA, in the process covering the origins of the mesenteric and renal arteries. B, A 4-branch Dacron graft is used to bypass the left renal, superior mesenteric, celiac, and right renal arteries, all in an end-to-end fashion. As in A, all aortic side branches are sequentially ligated at their origins to prevent type II endoleak and divided with subsequent anastomosis to the branches of the Dacron graft. Endovascular aneurysm exclusion is performed during the same operation, immediately after completion of the debranching procedure. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 21-28.e6DOI: (10.1016/j.jtcvs.2008.02.051) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 A, Drawing demonstrating stent graft being introduced antegradely across the aortic arch via the proximal antegrade limb of the debranching graft. B, After the stent graft is deployed in position, the proximal antegrade Dacron limb is oversewn and divided. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 21-28.e6DOI: (10.1016/j.jtcvs.2008.02.051) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Off-pump arch debranching procedure using a trifurcated Dacron graft Off-pump arch debranching procedure using a trifurcated Dacron graft. A, Intraoperative photograph of partial occlusion clamp placed on proximal ascending aorta for creation of proximal inflow anastomosis of trifurcated graft. B, Completed arch debranching procedure with first side branch of trifurcated graft oversewn and not used, second side branch anastomosed end to end to proximal left common carotid artery, and distal main body anastomosed end to end to proximal innominate artery. Note radiographic markers placed around proximal anastomosis to facilitate identification of the graft origin under fluoroscopy. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 21-28.e6DOI: (10.1016/j.jtcvs.2008.02.051) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

A. Custom fabricated antegrade hybrid graft (Vascutek USA, Ann Arbor, Mich) designed for arch debranching and antegrade stent graft deployment across the aortic arch without the need for femoral exposure. The proximal 10-mm side arm allows introduction of the stent graft introducer sheath antegradely into the ascending aorta. The first distal side branch is used to bypass the left common carotid artery (L CCA), whereas the second distal side branch is used for the innominate artery. B, Intraoperative photograph demonstrating completed arch debranching. The stent graft will subsequently be introduced antegradely across the aortic arch via the proximal side arm. C, Artist's drawing of completed arch debranching with the antegrade graft. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 21-28.e6DOI: (10.1016/j.jtcvs.2008.02.051) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

A, Preoperative CT scan of a patient with the Marfan syndrome status-post prior extent II TAAA repair 6 years earlier, who was discovered on follow-up imaging to have an asymptomatic 8.7-cm mesenteric button false aneurysm (arrow). B, Nine-month postoperative CT scan. Because the aortic bifurcation and bilateral common iliac arteries below the prior TAAA graft were aneurysmal as well, the distal aorta and common iliacs were replaced with a bifurcated Dacron graft. The mesenteric debranching graft was then anastomosed end to side to this new distal aortic graft followed by endovascular false aneurysm exclusion. Note anastomoses to the superior mesenteric artery, right renal, and celiac axis (patient did not have a left kidney). The false aneurysm has been completely excluded by the stent graft with proximal and distal seal zones completely within Dacron grafts and not in the Marfan aorta. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 21-28.e6DOI: (10.1016/j.jtcvs.2008.02.051) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Intraoperative arteriogram demonstating debranching graft with inflow from left iliac and distal anastomoses to left renal, superior mesenteric, celiac, and right renal arteries. The celiac has been anastomosed end to side to the graft in this instance. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 21-28.e6DOI: (10.1016/j.jtcvs.2008.02.051) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Intraoperative photograph demonstrating completed debranching procedure with antegrade limb clipped and oversewn. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 21-28.e6DOI: (10.1016/j.jtcvs.2008.02.051) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions