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HYBRID PROCEDURES ALLOW
ENDOVASCULAR TREATMENT OF ANEURYSMS AND DISSECTIONS INVOLVING THE AORTIC ARCH
P. BERGERON, T.
DE

42

CHAUMARAY, P. COULON, A. SHAH, F. MARIOTTI, M. BOUKHRIS, J. GAY

Abstract
Purpose: We present mid-term results of the hybrid management of thoracic aortic aneurysms & dissections (TAAD) involving the aortic arch in high risk patients (HRP). Methods: From May 2001 to October 2005, we treated 32 patients by staged aortic arch debranching and endografting for thoracic aortic aneurysm (14; 43.8%), residual chronic dissection after surgical repair of the ascending aorta (4; 12.5%), acute type A dissections (4; 12.5%), false aneurysm of the ascending aorta (1; 3.1%) and type B dissections (9; 28.1%). We achieved left hemi-arch transposition on 14 patients (43.8%), total arch transposition on 13 patients (40.6%), ascending aortainnominate bypass plus carotido-carotid transposition in 4 (12.5%) and sole carotido-carotid bypass in 1 (3.1%). Staged endovascular exclusion was performed in all but 2 patients. Results: The combined surgical and endovascular immediate death rate was 6.3%, as was the combined early stroke rate. The two fatal outcomes were catheter-related: one iliac artery rupture and one left ventricle perforation with the guidewire. No immediate paraplegia was observed although 1 patient developed a reversible right lower limb deficit after 2 weeks. During a mean follow-up of 27±13 months, we had 2 deaths at 1 and 3 months, respectively, from cardiac and respiratory failure. The mid-term survival rate was 87.5%. Endoleaks on thoracic aortic aneurysms were found in only 1 case during follow-up (7%) and we had a patent false lumen at the thoracic level on dissections in 3 patients (17.6%). No stent related fistula was reported. Conclusions: HRP suffering from aneurysms and dissections involving the aortic arch may benefit from the staged hybrid surgical & endovascular strategy. Aortic endografting after surgical transposition is a challenging feasible technique that offers good mid-term results, and accessible to vascular surgeons. However, data from long-term follow-up on larger series are needed.

Introduction
The surgical repair of aortic arch aneurysms & dissections remains a high risk procedure, requiring extra-corporeal circulation and cerebral protection. There has been considerable progress in anesthesia, cerebral protection methods and intensive care management, but it did not manage to decrease the average mortality rate under 20% and risk of paraplegia under 10% 1. However, thoracic aneurysms and dissections that involve the aortic arch are excluded from the conventional endovascular therapy. The hybrid management of aortic arch disease has been proposed as an alternative to open surgery for HRP, and we here report our mid-term results and discuss about the literature.

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A

B

Fig. 42.1. – A) Example of an aortic arch aneurysm requiring total arch debranching & transposition before endovascular exclusion in a female patient. B) Example of a male patient suffering from residual dissection of the distal aortic arch after previous surgical replacement of the ascending aorta.

Materials and methods
From May 2001 to October 2005, 32 patients were admitted for an aneurysm or a dissection of the thoracic aorta involving the aortic arch (Fig. 42.1). The average age of this cohort of patients was 69±10.5 years old, ranging from 50 to 85, and the male/female ratio was 4.2. Amongst comorbidities, 25 patients (78%) presented with high blood pressure, previous sternotomy in 4 (12.5%), severe cardiac impairment (cardiac valvulopathy, ejection fraction <30%, previous coronary bypass and/or MI) in 46.8%, chronic pulmonary disease (FEV1<1l) in 37.5%, and advanced age (>70) in 18 (56.3%). Fourteen patients (43.8%) had thoracic aortic aneurysm, 9 (28.1%) had type B thoracic aortic dissection, 4 (12.5%) had residual dissection after surgical repair of the ascending aorta, 4 (12.5%) presented with acute type A dissection, and one had a pseudoaneurysm of the ascending aorta. Average aortic diameter was 67±10.9 mm (range: 45-85), and the diameter was exceeding 60 mm in 19 patients (59.4%). According to our retrograde classification (Fig. 42.2), we carried out 14 interventions (43.8%) in zone II, 13 interventions (40.6%) in zone III, and then 4 ascending aorta-innom-

Fig. 42.2. – This retrograde classification of proximal landing zones illustrates the need of supra-aortic vessels debranching in the context of hybrid management of the aortic arch. If the proximal landing zone lies in the descending aorta (Zone 0), no vessel transposition is needed. In zone I, the subclavian artery needs to be transposed or covered. In zone II, two vessels are debranched and transposed: the left subclavian common carotid arteries. In zone III, the 3 supra-aortic vessels need to be transposed, except the subclavian artery, which is not easily reachable by median sternotomy. The numbers of procedures reported in the figure do not include hybrid management of acute type A dissections (aorto-innominate bypass + antegrade carotido-carotid bypass) nor the case we had of reverse carotido-carotid bypass to treat a false aneurysm of the ascending aorta.

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A

B

C

D

Fig. 42.3. – Industrial stentgrafts that are suitable to cover whole or part of the aortic arch and descending aorta. A) the Medtronic Valiant® device complements the Talent® one; B) the WL. Gore TAG® has replaced the Excluder® endograft for a couple of years; C) the Cook Zenith® device; D) the newly released LeMaitre Vascular EndoFit® tapered stentgraft better fits to the true lumen in case of chronic dissection.

inate bypass (12.5%) combined to a carotido-carotid bypass for acute type A dissections, as well as one retrograde carotido-carotid bypass (3.1%) to treat the pseudoaneurysm of the ascending aorta. One patient with acute type A dissections did not receive the stentgraft due to the immediate thrombosis of the false lumen. Another patient with aortic arch aneurysm and hemi-arch transposition showed a too short proximal landing zone with intra-operative intravascular ultrasound, and would require total arch transposition. However, he has been refusing this option due to his old age. Thus 30 patients underwent endovascular arch lining, which was carried out 1 to 4 weeks after the surgical step. The femoral access was used preferentially, while an additional percutaneous humeral approach was used to mark the origin of the native inominate artery. Following total-arch transpositions, markers (metal clips) were placed beyond the bypass to limit the proximal landing zones. The precise positioning of the endograft at the proximal neck was assisted by injecting contrast medium on left oblique anterior view. Endovascular procedures were all performed without transient cardiac asystole. We used Medtronic Talent® endoprostheses in 12 patients (40%), WL. Gore Excluder® endoprostheses in 4 patients (13.3%) and the last WL. Gore TAG endograft in 7 (23.3%). The Cook Zenith® device was used in 5 patients (16.7%) and the new LeMaitre Vascular EndoFit® in two (6.7%) (Fig. 42.3).

Results
Immediate results
The stentgraft deployment was successful in all 29 patients and we had no misplacement of the endografts. One patient died at 3 days from multi-organ failure after rupture of the iliac artery, and another one died from left ventricle perforation due to guidewire maneuvers. The in-hospital death rate was 6.3%. We also observed one minor stroke after arch debranching and transposition, which worsened to major stroke after endolining. The endovascular step caused 1 new minor stroke within 48 hours due to the occlusion of the left CCA bypass, which was resolved by a secondary carotido-carotid bypass. The stroke

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rate was 6.3%. The Major Adverse Event (MAE) rate including early deaths and major strokes was 7.3%. All of major adverse events occurred on thoracic aortic aneurysms, while none was reported amongst aortic dissections. We had no case of paraplegia but one patient developed at 1 month a right lower limb deficit that was healed with CSF drainage, although it was not assessed from a medullar origin by an independent neurologist.

Follow-up period
3-D CT scan and x-ray examinations were achieved on all the patients before their discharge to serve as control images. During an average follow-up period of 27 months (range: 5.4-54.7), one patient died at 47 days from heart failure. Another one, who was oxygen-dependent, died at 3 months from acute respiratory worsening. The survival rate at 15 months was 84.6%. None of the patients had new neurological adverse event, neither medullar ischaemia leading to paraplegia. We observed one type 1 distal endoleak on an aneurysm, which was successfully treated by stentgraft extension, and 1 type 2 endoleak originating from the left subclavian artery and successfully coiled. On dissections, we observed 4 perfused false lumens at the thoracic level, which happened on residual dissections after open repair of the ascending aorta. One of them was antegrade, and 3 were from retrograde perfusion due to distal reentries. One retrograde perfusion was successfully treated by distal stentgraft extension, the other 3 remaining under close surveillance. The false lumen at the abdominal level remained perfused in all case and we did not observe any case of renal or visceral malperfusion. No endograft migration or fracture was observed, nor stengraft related complication such as aorto-esophageal fistula.

Discussion
The limits of conventional aortic arch surgery are due to the invasiveness of cardiopulmonary bypass with hypothermic circulatory arrest or antegrade cerebral perfusion, with up to 25% risk of stroke and death as described in Table 42.I 2-9. Although it offers satisfactory results in low risk patients, this technique is hardly applicable to high risk patients. The combined treatment offers an effective and viable alternative. But another minimally invasive alternative is the total endovascular repair, which is still experimental. Inoue et al. have reported 1 case of triple-branched stengraft use 10. As for hybrid strategies, Chuter has reported a branched stentgraft to the inominate artery 11, 12, but without mid-term results. Several combined solutions have been proposed to treat aortic diseases extending to the aortic arch 13-19. Retrograde bypass from the right common iliac artery to the inominate artery suggested by Criado 18-19 does not appear satisfactory for brain vascularisation. As also demonstrated by Allenberg 20, sternotomy remains at low risk for high risk patients and allows a more physiological cerebral blood supply. We do not consider isolated transpositions of the left subclavian artery. In our experience, we have very few indications for it: – when the subclavian artery is included in the aneurysm, since it may lead to a type 2 endoleak;

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TABLE 42.I. – Literature review of the largest (>40 patients) recent series in the surgical repair of aneurysms and dissecting aneurysms extending to the aortic arch. * MANE: Major Adverse Neuro Events, including fatal & non fatal major strokes.
AUTHOR NUMBER MEAN AGE EARLY EARLY REOPERATION SURVIVAL OF PATIENTS STROKE/DEATH NEURO EVENTS (%) (%) (%) (%)

Tabayashi, 1994 2

77

NA

13

NA

NA

Okita, 1999 3 Jacobs, 2001 4 Kikuchi, 2002 5 Matsuda, 2002 6 Matalanis, 2003 7 Nakai, 2002 8 Niinami, 2003 9

246 50 60 101 62 109 43

NA 47 70.1 NA NA 71.7 67.5

25.6 12 4.9 8 14.4 21.3 21

11 10 3.2 NA 14.4 12.8 14

NA NA 10 8 NA NA NA

59% at 5Y (TAA)65.3% at 5Y (TAD) 64.6% NA 74.6% at NA 86.1% at 2Y 88.7% at 5Y 52% at 5Y29% at 10Y NA

– when the contralateral vertebral artery is stenosed or hypotrophic, not supplying the basilar artery; – when there is an incomplete fusion of both VAs at C1. In all other cases, its transposition is only required afterwards when the coverage becomes symptomatic. Furthermore, in case of hemi-arch debranching and transposition, the left subclavian artery is easily reachable by cervicotomy, but in case of median sternotomy for total arch transposition, it is very rarely reachable. In this case, even if it is included in the aneurysm, we prefer to transpose it after endolining, if it leads to type 2 endoleak and cannot be coiled. The hybrid strategy appears safe although catheter and guidewire-related complications may be fatal as proved by the fatal iliac artery rupture and the left ventricle perforation we encountered. It also seems that catheter maneuvers in front of a patent innominate artery ostium after hemi-arch transposition may be at higher risk for neurological hemispheric complications. Thus, total arch debranching and transposition may be safer for patients presenting a shaggy aorta. A possible way to reduce complications may be to perform pre-operative trans-esophageal echography to better select the patients. In order to reduce complications and potential infections, we prefer a staged procedure, which reduces the length of the operation and bleeding, as well as the time of x ray exposure above an open chest. The endografting final step after successful transposition is non invasive, percutaneous, and allows limited contrast injections. As a new development of the hybrid strategy, we developed the closed staged hybrid management of acute type A dissections by first replacing the ascending aorta, and then exclude the false lumen by endovascular means, provided a carotid-carotid transposition has been achieved. One-step open hybrid techniques have been recently reported 21, 22, which are usually performed under circulatory arrest. We here describe the first 4 cases of closed staged hybrid management of acute type A dissections. This option leads to a

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decreased mortality-morbidity rate with a preliminary valuable efficacy. However, it must be further investigated. The future of the challenging hybrid approach is depending on whether the endografting technology is reliable or not 23. Improvement of stentgrafting technique and devices is needed in terms of softness to improve aortic arch cruising and reduce the embolic risk. Recent reports also pointed out the need for the arch-specific devices. Conformation to the aortic arch lesser curvature may actually avoid the collapse of stentgrafts. Beveled stentgrafts could be the solution and be used for implantation on mid-arch landing zones.

Conclusions
We report mid-term results of a staged hybrid strategy to treat thoracic aortic aneurysms & dissections involving the aortic arch. It includes a first surgical step (debranching and transposition of supra-aortic carotid arteries) followed by an endovascular procedure. Accurate evaluation of the aortic neck and the proximal landing zone is mandatory for success of endolining. Since our results are encouraging, they allow high risk patients to be treated by the endoluminal route. However, the long-term results of this technique are still lacking, and comparative prospective studies are expected to provide formal proofs.

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