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J Thorac Cardiovasc Surg 2003;126:1186-1188
© 2003 The American Association for Thoracic Surgery

Brief communication

Endovascular flexible stent grafting with arch vessel bypass for a case of aortic arch aneurysm

Yoshio Nitta, MD, PhDa,*, Yusuke Tsuru, MD, PhDa, Kazuhiro Yamaya, MDa, Junetsu Akasaka, MD, PhDa, Katsuhiko Oda, MD, PhDa, Koichi Tabayashi, MD, PhDa

a Department of Cardiothoracic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan

Received for publication April 16, 2003; accepted for publication April 29, 2003.

* Address for reprints: Yoshio Nitta, MD, PhD, Department of Cardiothoracic Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryou-cho, Aoba-ku, Sendai, Japan 980-8575
ynitta{at}mail.cc.tohoku.ac.jp


See related articles on pages 1181 and 1184.

 

The Matsui-Kitamura (MK) stent graft (Kitagawa, Kanazawa, Japan) is designed to fit the curvy portions of the aorta because first-generation rigid skeleton–type stent grafts potentially cause kinking and endoleak as a result of limited flexibility.1-3 The MK stent graft consists of a custom-made, self-expandable spiral mesh of a single nitinol wire and thin-walled polyester fabric. We report the first surgical case of aortic arch aneurysm treated with this flexible and curved stent graft after extra-anatomic bypass of the arch vessels4 to prepare a landing zone for the stent graft.

Clinical summary

A 71-year-old man with distal arch aortic aneurysm diagnosed 2 months before in another hospital was referred to our hospital because blood-streaked sputum occurred gradually. Hypertension and severe chronic renal failure were also present. Magnetic resonance imaging revealed that the enlarged saccular-type aneurysm was pressing the lung, and this pressure was assumed to have caused the lung injury (Figure 1, A). The size and shape of the aorta were evaluated, and a suitable MK stent graft was ordered immediately.



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  		Figure 1. Preoperative magnetic resonance imaging (A) showed an extended saccular-type aortic arch aneurysm. Postoperative angiography (B) showed no endoleak around the MK stent graft that was inserted into the aortic arch. Stumps of the arch vessels were closed, and blood flows were restored through extra-anatomic bypass grafts.

 
After achievement of general anesthesia, 3 Dacron conduits with diameters of 8 mm were anastomosed to the right femoral and bilateral subclavian arteries. During these anastomoses, another straight conduit was anastomosed to a side of a Dacron Y graft (proximal diameter, 16 mm) to make the outflow tract of the graft triple. After median sternotomy, left heart bypass was established with the right upper pulmonary vein drainage cannula and bilateral subclavian arterial conduits. The patient was heparinized moderately before these cannulations, and the activated coagulation time was kept between 200 and 250 seconds. Left heart bypass was switched to antegrade selective cerebral perfusion (SCP) by placing clamps on 3 arch vessels and inserting an additional arterial cannula to the left common carotid artery (Figure 2, A). The arch vessels were divided, and their stumps were closed with 5-0 monofilament sutures. A side-biting clamp was placed on the ascending aorta, and the proximal end of the Y graft was anastomosed to the aorta in end-to-side fashion by using 5-0 monofilament sutures. Subsequently, the side-biting clamp was removed, and the 3 outflow tracts of the Y graft were anastomosed to the 3 arch vessels, respectively, in end-to-end fashion (Figure 2, C). After weaning from SCP, protamine was administrated once to stop bleeding. A sufficient landing zone was prepared for the proximal side of the stent graft by means of this extra-anatomic bypass. After light reheparinization, a sheath (5F) was inserted into the ascending aorta, a long guiding wire was inserted into the aorta through the sheath, and the wire was pulled out from the right femoral arterial conduit by using a snare catheter. The custom-made MK stent graft with a maximum diameter of 40 mm was delivered into the aortic arch through the right femoral arterial conduit by a long sheath catheter (Figure 2, C and D). Intraoperative angiography showed that the proximal end of the stent graft landed in the arch, the stent graft expanded and fit well to the wall, and no sign of the endoleak existed (Figure 1, B). Postoperative computed tomography showed that the size of the aneurysm was reduced. The patient's renal function recovered to preoperative levels after a transient use of hemodialysis. The patient was discharged from our hospital without blood-streaked sputum.



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  		Figure 2. The assisted circulation is shown in part A. Left heart bypass was switched to SCP by placing clamps on 3 arch vessels. An extended aortic arch aneurysm (B) was treated with the custom-made MK stent graft (D) that was inserted into the aortic arch after extra-anatomic arch vessel bypass construction (C).

 
Discussion

The MK stent graft is a flexible, custom-made, curved stent graft. It usually takes a week until we receive the stent graft after placing an order. In this case the MK stent graft fit tightly to the 3-dimensional curvy portion of the aorta and did not cause kinking or endoleak at all. Although total replacement of the aortic arch would be one of the best solutions for the aortic arch aneurysm, this procedure is surgically stressful, especially for patients with complications.5 Advantages of endovascular stent graft delivery with extra-anatomic arch vessel bypass by SCP are relief from cardiac arrest, relief from circulatory arrest, and relief from use of an oxygenator. The preoperative creatinine clearance value of this patient was 18 mL/min, and the postoperative renal function recovered to preoperative levels after transient use of dialysis. This suggested that the level of surgical stress of this procedure was acceptable for this patient. SCP alone requires lower levels of heparinization than cardiopulmonary bypass because of the lack of an oxygenator. It is a big advantage of this procedure to prevent bleeding in a patient with such potential for massive lung bleeding. To reduce the risk of brain complications, we closed the arch vessels before the use of the side-biting clamp.

Endovascular delivery of the MK stent graft with extra-anatomic arch vessel bypass by using SCP could be a useful and minimally invasive therapeutic strategy for patients with aortic arch aneurysms who are considered at high surgical risk.

References

  1. Dake MD, Miller DC, Mitchell RS, Semba CP, Moore KA, Sakai T. The "first generation" of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta. J Thorac Cardiovasc Surg. 1998;116:689–704[Abstract/Free Full Text]
  2. Mitchell RS, Dake MD, Sembra CP, Fogarty TJ, Zarins CK, Liddel RP, et al. Endovascular stent-graft repair of thoracic aortic aneurysms. J Thorac Cardiovasc Surg. 1996;111:1054–1062[Abstract/Free Full Text]
  3. Orihashi K, Matsuura Y, Sueda T, Watari M, Okada K, Sugawara Y, et al. Echocardiography-assisted surgery in transaortic endovascular stent grafting: role of transesophageal echocardiography. J Thorac Cardiovasc Surg. 2000;120:672–678[Abstract/Free Full Text]
  4. Kato M, Kaneko M, Kuratani T, Horiguchi K, Ikushima H, Ohnishi K. New operative method for distal aortic arch aneurysm: combined cervical branch bypass and endovascular stent-graft implantation. J Thorac Cardiovasc Surg. 1999;117:832–834[Free Full Text]
  5. Coselli JS, Buket S, Djukanovic B. Aortic arch operation: current treatment and results. Ann Thorac Surg. 1995;59:19–27[Abstract/Free Full Text]



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