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J Thorac Cardiovasc Surg 1999;117:832-834
© 1999 Mosby, Inc.

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NEW OPERATIVE METHOD FOR DISTAL AORTIC ARCH ANEURYSM: COMBINED CERVICAL BRANCH BYPASS AND ENDOVASCULAR STENT-GRAFT IMPLANTATION

From the Division of Cardiovascular Surgery, Osaka Prefectural Hospital, Osaka, Japan.

Received for publication Nov 23, 1998. Accepted for publication Nov 27, 1998. Address for reprints: Masaaki Kato, MD, Division of Cardiovascular Surgery, Osaka Prefectural Hospital, 3-1-56 Mandai-higashi, Sumiyoshiku Osaka 558-8558, Japan.

Surgical treatment of distal aortic arch aneurysm still results in many problems: direct lung injury, phrenic or recurrent nerve paralysis, cerebrovascular complications, and clotting disturbances. ^1,2 Although endoluminal stent-graft implantation for thoracic aortic aneurysm is less invasive, ^3,4 the curve of the aortic arch and the need to maintain supply to the cerebral branches make it difficult to apply this approach in the case of distal arch aneurysm. Therefore we have developed and now applied a new stent-graft implanting method that uses cervical branch bypasses from the ascending aorta and requires no extracorporeal circulation (ECC) and no aortic crossclamping.

Clinical summary
The patient was a 76-year-old man with an abdominal and a thoracic aneurysm. A preoperative computed tomographic scan and aortography showed a saccular aneurysm in the distal aortic arch and an ulcerlike projection in its lesser curve (Fig. 1, A and B). Seventeen years earlier, he had had a cerebral infarction. Magnetic resonance imaging documented many infarcts in the deep white matter, but magnetic resonance angiography, a Matas test, and a cerebral scintiscan demonstrated good patency of the Willis arterial circle and indicated that the carotid artery could be safely occluded. An operation to repair the thoracic aneurysm was performed 3 months after the repair of the abdominal aneurysm.

View larger version (112K): [in this window] [in a new window]   Fig 1. Preoperative (A and B) and postoperative (C and D) aortograms and computed tomograms. A, Preoperative aortogram shows the saccular projection in the distal aortic arch (large arrow) and small ulcer-like projection (small arrows) in the lesser curve. B, Enhanced computed tomogram shows the saccular aneurysm with thrombus in the distal arch. C, Postoperative aortogram shows bypasses to the left carotid artery and left subclavian artery, and stent-graft implanted in the arch–descending aorta. D, Postoperative computed tomogram shows the clot formation in the saccular projection that was excluded by the stent-graft.

View larger version (29K): [in this window] [in a new window]   Fig 2. Schema of the new stent-graft implantation method for distal aortic arch aneurysm. A, The main portion of the bifurcated graft is anastomosed to the ascending aorta. B, After bypasses have been established to the left carotid and left subclavian arteries, a 30F sheath containing the specially devised stent-graft is inserted, extending from the ascending aorta to the descending aorta. C, The stent-graft is deployed from the aortic arch to the descending aorta.

Comment
This operative approach represents two advances. First, it is less invasive than previous techniques. In 1995 we had begun substituting the stent-graft for distal anastomosis in the repair of aortic arch disease. ⁵ Although this method reduced the complications associated with suture anastomosis in the descending aorta and decreased the mortality and morbidity of aortic arch surgery, it remained quite invasive because of hypothermic ECC and circulatory arrest distal to the left subclavian artery. The new method does not require ECC or aortic crossclamping, and substituting the stent-graft for proximal suture anastomosis avoids distal malperfusion.

Second, it avoids proximal perigraft leakage, which often accompanies aortic transcatheter stent-graft implantation via the femoral artery. ^3,4 The main cause of the leakage is incomplete attachment of the stent-graft because of an insufficiently large attachment area between the stent-graft and aortic wall, as well as the curve just distal to the left subclavian artery. Our new method solves this problem by providing a long, straight attachment area between the stent-graft and aortic wall via bypass from the ascending aorta to the left carotid and left subclavian arteries.

References

1. Miller DC, Mitchell RS, Oyer PE, Stinson EB, Jamieson SW, Shumway NE. Independent determinant of operative mortality for patients with aortic dissections. Circulation 1984;70(Suppl):I152-64.
   
2. Coselli JS, Buket S, Djukanovic B. Aortic arch operation: current treatment and results. Ann Thorac Surg 1995;59:19-26. [Abstract/Free Full Text]
   
3. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddle RP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysm. N Engl J Med 1994;331:1729-34. [Abstract/Free Full Text]
   
4. Mitchell RS, Dake MD, Semba CP, Fogarty TJ, Zarins CK, Liddle RP, et al. Endovascular stent-graft repair of thoracic aortic aneurysms. J Thorac Cardiovasc Surg 1996;111:1054-62. [Abstract/Free Full Text]
   
5. Kato M, Ohnishi K, Kaneko M, Ueda T, Kishi D, Mizushima T, et al. A new grafting-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation 1996;94(Suppl):II188-93.
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Masaaki Kato Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kato, M. Articles by Ohnishi, K. Search for Related Content PubMed PubMed Citation Articles by Kato, M. Articles by Ohnishi, K.