Hybrid Repair of an Aortic Arch Aneurysm Using Double Parallel Grafts Perfused by Retrograde Flow in Endovascular Repair Combined With Left Subclavian Artery Surgical Bypass

Abstract

Despite its invasive nature, open surgical repair is still the first choice to treat aortic arch aneurysms. With the advancement of endovascular technology, thoracic endovascular aortic repair (TEVAR) has gained popularity in treating aortic aneurysms; however, blood flow preservation of the supra-arch branches remains a complicated challenge. This case report describes a hybrid procedure that successfully treated a patient with aortic arch aneurysm by combining the parallel grafts perfused by retrograde flow in the TEVAR procedure and a carotid-subclavian artery bypass.

Sandwich Technique for Endovascular Repair of Acute Type A Aortic Dissection

“…Once in our experience a kinking Fluency stent-graft (Bard Peripheral Vascular, Tempe, AZ, USA) was relined with a balloon-expandable stent as a periscope in the LCCA to treat aortic arch aneurysm. 12…”

“…Thus, the high-speed aortic flow could lead to a type I endoleak. In contrast, in the periscope technique, [7][8][9][10][11][12][13] the reconstruction of the supra-arch branches is located in the aortic stent-graft, with the periscope grafts perfused in a retrograde manner, thus avoiding the rush of blood toward the gutters. Therefore, blood in either the stent-grafts or the gutters is driven only by the pressure difference, and the blood in the gutters could easily form clots when the blood remains static at a balanced pressure between the true and false lumens.…”

“…A preoperative bench simulation ( Figure 3A) based on 3-dimensional CTA would be helpful. 12 The periscope graft should be deployed more distally than the aortic stent-graft to ensure that the former will not be covered by the latter. One concern is that the periscope graft might be displaced by aortic blood flow; therefore, the aortic stent-graft is deployed first and stent-grafts in the branches second, regardless of whether the smaller stent-grafts cross or are parallel ( Figure 5).…”

“…Once in our experience a kinking Fluency stent-graft (Bard Peripheral Vascular, Tempe, AZ, USA) was relined with a balloon-expandable stent as a periscope in the LCCA to treat aortic arch aneurysm. 12 Stent-grafts used in the ascending aorta should be soft and pliable. A stent-graft without a bare stent at the proximal end is best; otherwise, the bare stent should be as short as possible.…”

Modification in aortic arch replacement surgery

“…Although simplified, this procedure remains a major surgery for patients experiencing great distress, malperfusion, and abnormal hemodynamics resulting from an aortic dissection type A. If a sufficient segment of normal ascending aorta remains, a TEVAR procedure, which reserves the supra-arch branches, or a debranch procedure is recommended for simplicity and safety [ 4 ]. There remains room for potential improvements to further simplify this technique in the future.…”