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Use of Custom Dacron Branch Grafts for “Hybrid” Aortic Debranching During Endovascular Repair of Thoracic and Thoracoabdominal Aortic Aneurysms.
G. C. Hughes, J. J. Nienaber, E. L. Bush, M. A. Daneshmand, R. L. McCann. Duke University Medical Center, Durham, NC,
BACKGROUND: Endovascular repair of descending thoracic aortic pathology is emerging as the preferred treatment strategy in a majority of patients. However, a significant number of patients have anatomy unsuitable for endovascular repair due to inadequate stent graft seal zones. “Hybrid” techniques, including open aortic arch or thoracoabdominal debranching procedures, allow creation of proximal and/or distal landing zones and expand the potential applications of endovascular repair. We report our experience with aortic arch and thoracoabdominal debranching using custom Dacron branch grafts, which greatly simplify aortic debranching by providing inflow via a single anastomosis.
METHODS: Between 11/14/05-12/18/06, a total of 53 thoracic endograft procedures were performed at our institution. Of these, 13 (25%) involved either open aortic arch or abdominal debranching to create proximal (PLZ) or distal landing zones (DLZ) for endovascular repair. Patients undergoing arch debranching (n=7) had aneurysms involving the transverse arch with <2 cm of PLZ distal to the innominate artery, necessitating stent graft coverage of both the innominate and left common carotid arteries. Arch debranching was performed via median sternotomy with inflow from the proximal ascending aorta without cardiopulmonary bypass (CPB) using trifurcated grafts originally designed for head vessel reimplantation during open total arch replacement or with a new “hybrid antegrade graft” designed to debranch the innominate and left common carotid arteries with concomitant antegrade stent graft insertion across the aortic arch without the need for femoral exposure. Patients undergoing complete abdominal debranching (n=6) had either thoracoabdominal aortic aneurysms (TAAA) (Extent II, n=1; Extent V, n=3) or mesenteric button false aneurysms following prior open TAAA repair (n=2). Abdominal debranching was performed via midline laparotomy with inflow via a single proximal anastomosis from the infrarenal aorta (n=1) or iliac system (n=5) using either trifurcated or 4-vessel branch grafts with distal anastomoses to the superior mesenteric artery, left renal artery, celiac axis, and right renal artery. In all cases, endovascular aneurysm exclusion was performed at the same operation using the Gore TAG device.
RESULTS: Mean patient age was 63+11 years (range 46-83); all patients had significant comorbidities, including prior open aortic surgery in n=8 (62%). 30 day mortality was 0%; there were no permanent neurologic deficits, either CVA or paraparesis/paraplegia. One patient with an Extent II TAAA undergoing complete abdominal debranching had transient paraparesis on POD#1, which completely resolved with BP augmentation and CSF drainage. At a median follow-up of 6 months, there has been no late morbidity or mortality; all bypass grafts remain patent without need for further intervention. CT scans demonstrate no endoleaks and all aneurysms are thrombosed with stable (n=6) or decreasing aortic dimensions (n=7).
CONCLUSIONS: “Hybrid” aortic debranching using custom Dacron branch grafts with a single inflow source combined with endovascular aneurysm exclusion appears to be a safe alternative to standard open repair for thoracoabdominal and aortic arch aneurysms and avoids the need for CPB and aortic cross-clamp. This technique may be ideally suited to patients with significant comorbidity or prior open aortic surgery. Longer term follow-up is needed to determine the durability of this approach.
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