Open techniques for arch vessel reconstruction during thoracic endovascular aneurysm repair (TEVAR)

Abstract

Over the past several years, the use and applications of thoracic endovascular grafts have increased significantly. There are now three FDA approved devices for thoracic endovascular aneurysm repair (TEVAR) available in the United States. These new devices have allowed us to expand the number of patients as well as the conditions we treat with this technology. However, many patients are not candidates for traditional endovascular repair because of unsuitable anatomy for use of these devices. Commonly, this is due to an inadequate proximal landing zone on the aortic arch. The recommended proximal landing zone for thoracic endograft devices is typically 2 to 3 cm of seal. To achieve this proximal landing zone, up to 40% of thoracic aneurysms may require coverage of critical supra-aortic arch vessels including or proximal to the left subclavian artery. 1 In this article, we will discuss the open surgical alternatives and techniques available in managing the proximal arch vessels in patients who have complex thoracic aortic anatomy. THORACIC ANEURYSMS ENCROACHING OR INVOLVING THE ORIGIN OF THE LEFT SUBCLAVIAN ARTERYThere has been considerable debate over the safety of coverage of the left subclavian artery. 2-6 The Society for Vascular Surgery ® (SVS) suggests routine preoperative revascularization for all elective TEVAR patients. 7 There are many ways to revascularize the subclavian artery depending on the individual patient's anatomy. The operations most commonly performed in these situations are transposition of the subclavian artery to the carotid artery or a carotidsubclavian bypass using a prosthetic graft. Both of these have excellent long-term outcomes with long-term patency of carotid-subclavian bypass being 86% and subclaviancarotid transposition approaching 100% in the hands of experienced surgeons. [8][9][10][11][12] Bypass with prosthetic grafts should be performed in patients with very proximal vertebral artery takeoffs, which prohibit subclavian artery transection proximally through a supraclavicular approach (Fig 1). A bypass procedure should also be preferentially used in patients who have a patent coronary bypass graft originating from the left internal mammary artery to help prevent coronary ischemia during clamping. Axillary-axillary artery bypasses and subclavian-subclavian artery bypasses have also been described in the literature for revascularization. 13 A type II endoleak may occur if the subclavian artery is not ligated proximally during revascularization. Carotidsubclavian bypass allows left brachial access to the aorta, which may be useful for embolization of the subclavian artery after coverage with an aortic endograft. In emergent situations where no revascularization is performed, coil embolization via the brachial artery can be performed if an endoleak persists at follow-up imaging.When performing these operations, a few technical tips may help reduce the risk of complications. One of the major risks of either of these procedures is a phrenic nerve injury. The phrenic nerve is visuali...

Staged hybrid repair for symptomatic extensive aortic aneurysm from distal ascending across aortic arch till supraceliac thoracic aorta

“…In addition, cerebrospinal fluid drain helped monitor and optimize pressure for spinal cord protection. 2 Pan-supra-aortic debranching supported by bilateral innominization along with stenting of iliac artery for access of stent grafts for endovascular repair in this septuagenarian is an extremely rare reported experience in the literature.…”

Intentional coverage of the celiac artery during thoracic endovascular aortic repair

“…In cases where the proximal landing zone is inadequate, coverage of the left subclavian artery (with or without revascularization) or extra-anatomic revascularization are accepted techniques to expand the use of TEVAR to treat patients with TAAs. 3,4 However, optimal treatment in patients with insufficient distal landing zones remains unclear. Intentional ligation of the CA in the treatment of TAAs was first described by Lawrence-Brown et al in 2000.…”

“…3 Extra-anatomic arterial revascularization (such as carotid-carotid bypass or total arch debranching) is another alternative to extend the proximal landing zone. 4 Approximately 15% of patients with descending thoracic aortic aneurysms (TAAs) have an insufficient distal landing zone for TEVAR. 5 While standard open reconstruction is a potential option, this procedure is associated with high rates of periprocedural adverse events (including paraplegia and mortality).…”

A technical improvement in retropharyngeal carotid reconstruction

“…Later, a left carotid-subclavian bypass with a 7-mm-polytetrafluoroethylene graft was performed. 3 In the second stage, sealing of the proximal type I endoleak (Fig 4) was achieved with the deployment of a 40-mm ϫ 20-cm Medtronic-Valiant endoprosthesis (Medtronic, Galway, Ireland). Immediate postoperative recovery was satisfactory and at 1-month follow-up, the patient is complication-free.…”