Hybrid Debranching of Aortic Arch Branches and Endovascular Repair of the Aneurysm of the Aortic Arch and the Thoracic Aorta

Recently, hybrid approaches for the treatment of thoracic aortic pathologies have gained popularity as a means to decrease morbidity and mortality associate with conventional total aortic arch replacement. In this video, the authors provide insights into their surgical approach for hybrid management of an aneurysm in the aortic arch and thoracic aorta secondary to Stanford type B aortic dissection. 

Case Presentation 

A 51-year-old male, who was initially under follow-up for Stanford type B aortic dissection, presented with a rapidly expanding aneurysm of the thoracic aorta (from 43 to 64 mm) seven months after acute dissection. Dilation of the aortic arch was also noted, with a diameter of 42 mm. His medical history was notable for poorly controlled arterial hypertension. Given this alarming progression, the surgeons planned a hybrid approach with debranching of the arch branches and thoracic endovascular aortic repair (TEVAR). 

Surgery 

Under general anesthesia, the right axillary artery was explored, and an 8 mm Dacron graft was anastomosed to the axillary artery to perform antegrade cerebral perfusion via a passive shunt during off-pump debranching of the arch branches. After sternotomy, the ascending aorta, aortic arch, and the supra-aortic branches were exposed. Following systemic heparinization, an 18 x 9 mm Y Dacron graft was anastomosed to the proximal ascending aorta with a side-biting clamp. One of the branches of the Y graft was dedicated to providing cerebral perfusion via the right axillary artery during the brachiocephalic trunk anastomosis. The brachiocephalic artery was transected from its origin and anastomosed to the other branch of the Y graft. The left carotid artery was then anastomosed to the remaining branch of the graft. 

After an uneventful two-day postoperative course, the patient underwent TEVAR. The challenge was that the true lumen was severely compressed by the false lumen, and there were multiple re-entries throughout the dissection. Through the left femoral artery, the true lumen was accessed at the level of the aortoiliac bifurcation. The guidewire was advanced toward the proximal thoracic aortic segments following the true lumen. As an adjunct, transesophageal echocardiography was utilized to monitor the position of the guidewire throughout the true lumen. The ascending aorta proximal to the brachiocephalic artery take-off (zone 0) was chosen as the proximal landing zone. The aortography showed that the false lumen was being fed by the left subclavian artery. After accessing the left brachial artery, a vascular plug was deployed precisely at the subclavian artery's orifice. Subsequent control imaging definitively confirmed the effective occlusion of the subclavian artery, leading to the immediate cessation of the leak. 

Postoperative Course 

The patient had an uneventful postoperative follow-up and was discharged from the hospital on postoperative day 10. Control CT angiography three months post operation showed no leaks or disease progression. The hybrid approach presents a promising and effective strategy for addressing complex aneurysms involving the aortic arch and thoracic aorta. 

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