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J Thorac Cardiovasc Surg 2007;133:262-263
© 2007 The American Association for Thoracic Surgery

Brief Communication

Endovascular repair of aortic arch aneurysm after achievement of local anesthesia

Giuseppe Siniscalchi, MD*, Piergiorgio Tozzi, MD, Enrico Ferrari, MD, Dominique Delay, MD, Patrick Ruchat, MD, Ludwig von Segesser, MD

Cardiovascular Surgery Department, Centre Hôpitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland.

Received for publication September 7, 2006; accepted for publication September 13, 2006.

* Address for reprints: Giuseppe Siniscalchi, MD, Department of Cardiovascular Surgery, Centre Hôpitalier Universitaire Vaudois (CHUV), 46, rue du Bugnon, CH-1011 Lausanne, Switzerland. (Email: giuseppe.siniscalchi{at}chuv.ch).


Figure 1
Drs Tozzi, Von Segesser, Siniscalchi, Ferrari, Delay, Fischer (senior cardiac surgeons not author), and Ruchat (right to left)


Endovascular treatment of aortic arch aneurysm represents a major challenge, mainly because brain perfusion can be easily compromised during the procedure.

We share our experience with the hybrid approach to aneurysm of the aortic arch in a patient with prohibitive risk for aortic arch replacement under extracorporal circulation.1-4Go The hybrid approach includes the construction of a prosthetic bypass between the right and left carotid arteries, followed by the deployment of an endoprosthesis in the aortic arch after achievement of local anesthesia.

In a 72-year-old obese (body mass index, 40) patient with chronic obstructive pulmonary disease (forced expiratory volume in 1 second, <0.75 L), cardiac failure (left ventricular ejection fraction, 25%), and renal failure (creatinine clearance, 62 mL/min), a computed tomographic scan showed a saccular aneurysm of the aortic arch extending to 1 cm distal to the origin of the brachiocephalic trunk to 3 cm distal to the left subclavian artery, with a maximum diameter of 70 mm. The patient’s EuroSCORE was 16, and predictive mortality was 68.71%.

Technique

We approached the aortic arch aneurysm repair after achievement of local anesthesia. The surgical strategy consisted of 2 steps. First, we performed a bypass between the right and left carotid arteries with an 8-mm e-PTFE prosthesis and occluded the left carotid artery proximally to the bypass. Then through a left femoral artery approach, an endoprosthesis was introduced under fluoroscopy and intravascular ultrasonographic control and controlled hypotension (50 mm Hg).3Go We choose an endoprosthesis with a diameter of 40 mm and a length of 115 cm, with an oversizing of 20%.

The endoprosthesis was deployed in such a way that the bare springs were on the origin of the brachiocephalic trunk (Figure 1).


Figure 1
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  		Figure 1. The aortic arch aneurysm has been excluded, deploying an endoprosthesis in such a way that the bare springs were on the origin the brachiocephalic trunk. The left carotid artery and left subclavian artery have been occluded. The prosthetic bypass between the right and left carotid arteries guarantees optimal cerebral perfusion.

 
Fluoroscopy and transesophageal echocardiography were performed to confirm appropriate graft deployment and the absence of endoleaks. No contrast medium was used. The postoperative period was eventful, and the patient was discharged on day 4. An injected computed tomographic scan performed on day 6 confirmed the absence of endoleak (Figure 2).


Figure 2
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  		Figure 2. Computed tomographic scan on day 6 postoperatively confirmed the complete exclusion of the aneurysm.

 
Discussion

It is possible to treat aortic arch aneurysm after achievement of local anesthesia,4Go and we believe this surgical strategy should be considered as a potential alternative to conventional aortic arch aneurysm surgery in high-risk patients.

References

  1. Niinami H, Aomi S, Chikazawa G, Tomioka H, Koyanagi H. Progress in the treatment of aneurysms of the distal aortic arch: approach through median sternotomy. J Cardiovasc Surg 2003;44:243-248.[Medline]
  2. Taylor BV, Kalman PG. Saccular aortic aneurysms. Ann Vasc Surg 1999;13:555-559.[Medline]
  3. Ishimaru S. Endografting of the aortic arch. J Endovasc Ther 2004;11(suppl 2):II62-II71.
  4. Verhoeven EL, Cina CS, Tielliu IF, Zeebregts CJ, Prins TR, Eindhoven GB, et al. Local anesthesia for endovascular abdominal aortic aneurysm repair. J Vasc Surg 2005;42:402-409.[Medline]



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