Extra-anatomic bypass with open-plugging stent graft for extensive dissected aortic aneurysm

Abstract

Treatment for an extensively dissected aortic aneurysm is a surgical challenge. Open surgery using a left thoracotomy is promising but can be dangerous in patients with pulmonary comorbidity. We treated a 63-year-old man with chronic type B aortic dissection with aneurysmal change and ascending aortic dilation. The thoracoabdominal aorta was also dissected, dilated, and tapered; thus, a simple hybrid strategy was not possible, even with open fenestration. We performed ascending aortic replacement with reconstruction of the cervical vessels and extra-anatomic bypass from the ascending to descending aorta, with aneurysmal isolation. A stent graft was inserted at the true lumen of the residual aneurysm to reduce endopressure. Total thrombosis and reduction in size of the aneurysm was achieved, and the patient recovered well, without complications. (J Vasc Surg Cases 2015;1:32-5.) Surgical repair of extensive dissected aortic aneurysm is challenging. Patients are often complicated by postoperative pulmonary complications. Avoiding graft replacement through a left thoracotomy is preferable in patients with pulmonary comorbidity. Extra-anatomic bypass with aneurysm isolation, first described by Carpentier et al, 1 can be performed through a median sternotomy, with or without an upper laparotomy. However, this technique is rarely used currently because backflow from intercostal arteries and mediastinal branches is uncontrollable and the longterm result is unwarranted.We here present a case of a patient with obstructive pulmonary disease and an extensively dissected aortic aneurysm who was successfully treated by extra-anatomic bypass. The aneurysm was isolated, and a stent graft was inserted into the true lumen of the aneurysm to reduce type II endoleak from intercostal arteries. Patient consent to the publication was obtained. CASE REPORTA 63-year-old man was emergently admitted to our hospital with sudden onset of chest pain. His medical history included type B aortic dissection 12 years before the admission, emphysema from cigarette smoking, mild renal dysfunction, and alcoholic liver dysfunction. He was obese (body mass index, 31.9 kg/m 2 ). Shock was not present.A contrast-enhanced computed tomography (CT) scan on admission revealed a dissected aortic aneurysm from the aortic arch to the bilateral common iliac arteries. The maximum diameter of the descending aorta was 68 mm, and the aorta around the origin of the celiac artery was tapered (diameter range, 38-46 mm ; Fig 1, A). The ascending aorta was also dilated (maximum diameter, 51 mm). There was mediastinal hematoma with no extravasation, indicating contained rupture.Because the patient had no symptoms after administration of antihypertensive therapy, no progressive anemia, and had stable circulatory condition, we opted for intentionally delayed surgery. A simple extensive graft replacement via left thoracotomy was contraindicated due to the risk of postoperative pulmonary morbidity. A two-stage hybrid procedure, including the open fenestration technique was...