|Year : 2022 | Volume
| Issue : 1 | Page : 11-17
Evolving paradigm of hybrid repair for aortic arch pathologies
Madathipat Unnikrishnan1, Sidharth Viswanathan2, Shivanesan Pitchai3, Ajay Savlania4, Harishankar Ramachandran5, Vineeth Kumar P M6, Arun Mohan Mohanan7, Praveen Gopalakrishnan8, Kapilamoorthy T R9, Prasanta Kumar Dash10
1 Division of Vascular Surgery and Endovascular Surgery, BR Life SUT Hospitals; Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
2 Department of Vascular and Endovascular Surgery, Amrita Institute of Medical Sciences, Kochi; Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
3 Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
4 Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh; Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
5 Department of Vascular and Endovascular Surgery, Starcare Hospital, Calicut; Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
6 Department of Vascular and Endovascular Surgery, Jubilee Mission Medical College, Thrissur; Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
7 Department of Radiology, BR Life SUT Hospitals, Thiruvananthapuram, Kerala, India
8 Department of Cardiology, BR Life SUT Hospitals, Thiruvananthapuram, Kerala, India
9 Department of Radiology, JSS Medical College, Mysore, Karnataka; Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
10 Department of Anesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
|Date of Submission||04-Jul-2021|
|Date of Acceptance||10-Jul-2021|
|Date of Web Publication||23-Mar-2022|
Division of Vascular Surgery and Endovascular Surgery, BR Life SUT Hospitals; Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
Source of Support: None, Conflict of Interest: None
Background: Critical domain of thoracic aorta, the aortic arch, is affected by diverse pathologies mandating effective yet less strenuous management to save life, preserve organ function, and provide quality of life. Conventional open repair, minimally invasive total endovascular, and hybrid aortic arch repair are therapeutic options available. We present our experience and results with hybrid arch procedures. Materials and Methods: A cohort of 75 patients who were operated upon by the senior author from 2007 to 2020 formed the basis for this report. Male: female ratio was 11:1 for this group whose age ranged from 22 to 82 years with a mean of 70. Clinical indications were degenerative aneurysm (n = 49), Stanford B aortic dissection (n = 21), residual lesion following earlier Stanford A repair (n = 4) and a solitary patient with aortic trauma. Pan-arch debranching or hemi-arch debranching was performed in nearly all along with deployment of stent-graft at Zone 0 or Zone I, respectively. Sixty-seven elective (89.3%) procedures were staged and 8 (10.7%) were synchronous on account of being emergency interventions. Postoperative follow-up was performed at 3 and 6 months and yearly. Computed tomography aortogram was done before discharge from hospital or within 1 month followed by 1 year. Results: Technical success was achieved in 97.3%. Inhospital/30-day mortality was 9.3% (7/75 patients). Neurological complications, albeit less common, were the leading cause of perioperative morbidity. No endoleaks or graft migration was encountered in follow-up. Late mortality occurred in 10.3% (7/68 patients) from 6 months to 5 years, with massive hemoptysis in three despite asymptomatic clinical status and satisfactory imaging. Two patients were lost for follow-up, while the rest 59 patients are keeping well. Conclusion: Hybrid repair of aortic arch lesions, though initially intended to compliment stressful conventional surgery, has now evolved as the primary modality in this domain. This relatively safe therapeutic option, performed in a staged setting coupled with attention to achieve a liberal proximal seal, provided excellent initial results and long-term survival.
Keywords: Aortic arch, aneurysm, aortic dissection, hybrid repair, stent-graft, debranching
|How to cite this article:|
Unnikrishnan M, Viswanathan S, Pitchai S, Savlania A, Ramachandran H, Kumar P M V, Mohanan AM, Gopalakrishnan P, KapilamoorthyT, Dash PK. Evolving paradigm of hybrid repair for aortic arch pathologies. Indian J Vasc Endovasc Surg 2022;9:11-7
|How to cite this URL:|
Unnikrishnan M, Viswanathan S, Pitchai S, Savlania A, Ramachandran H, Kumar P M V, Mohanan AM, Gopalakrishnan P, KapilamoorthyT, Dash PK. Evolving paradigm of hybrid repair for aortic arch pathologies. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 May 28];9:11-7. Available from: https://www.indjvascsurg.org/text.asp?2022/9/1/11/340509
| Introduction|| |
The aortic arch, strategically placed domain of the thoracic aorta, is home for cerebral and brachiocephalic circulations and provides inflow for spinal cord, viscerorenal, and lower limb circulations as well. Diverse pathologies of degenerative aneurysm, Stanford A and B dissections, and traumatic injury afflicting aortic arch call for expeditious management to save life, preserve system function, and provide quality of life. Since most lesions involve proximally the ascending aorta and distally descending aorta beyond the arch, treatment involves cardiopulmonary bypass and various modifications thereof for circulatory assistance. The gold standard conventional surgical procedure carries significant morbidity and mortality particularly in elderly and system compromised patients. Ever since Michael Dake from Stanford University popularized thoracic endovascular aneurysm repair (TEVAR) as a minimally invasive procedure, it has evolved as a competitive option to open surgery, soon becoming the treatment of choice in view of it being both minimally stressful and effective. Critical protection and preservation of cerebrospinal circulation is achieved by total endovascular therapy with adjuvants of fenestration/chimney techniques and alternatively by combining surgical debranching and stent-graft deployment alias hybrid arch repair. We describe our surgical mid-term outcomes following hybrid aortic arch repair performed by the first author.
| Materials and Methods|| |
This report is based on a retrospective analysis of consecutive 75 patients who underwent hybrid repair of aortic arch pathologies at two institutions by the senior author between September 2007 and November 2020. Clinical indications included Degenerative Arch Aneurysm (n = 49), Stanford Type B aortic dissection (TBAD) (n = 21), Chronic Residual Arch and Descending Aortic dissection following prior repair of Stanford A dissection (n = 4), and a lone traumatic rupture of descending thoracic aorta [Table 1]. Eight patients mandated emergency intervention following rupture.
Necessary blood tests including serum creatinine and blood grouping, if not available already, were called for in emergent cases who were admitted in intensive care unit (ICU) for brief period of time, while procedural planning was being undertaken, before being shifted to operation room. While in ICU, invasive monitoring including arterial line, central venous catheterization, large-bore peripheral lines, and urinary bladder catheterization were performed. Elective patients were investigated and managed as per the standard protocol for aortic surgery of our institutes that included noninvasive cardiac assessment.
All patients underwent prior contrast computed tomography (CT) aortography. An inter-departmental discussion with interventional radiology colleagues is always undertaken to review the imaging in detail and decide proximal and distal landing zones and hence appropriate debranching strategy, stent-graft sizing, and arterial access. Bailout plans like on-the-shelf readiness with a second stent-graft or covered stent for branch compromise were also contemplated. Method of inducing hypotension during deployment to abate the windsock effect by either transvenous pacing, adenosine, or vasodilators as deemed appropriate to the index patient was finalized. Whenever arch affliction involved the entire descending thoracic aorta, cerebrospinal fluid (CSF) drainage was placed to optimize CSF pressure as a spinal cord protection strategy.
General anesthesia is mandatory, so used, in our experience for the procedure. Synchronous procedure, namely appropriate debranching followed by stent-graft deployment immediately after, was employed only in ruptured/threatened rupture setting. In all elective cases, staged procedure was our strategy with debranching being performed first and stent-graft deployment done the next day or two days later [Figure 1].
|Figure 1: (a) Computed tomography angiogram volume rendered (three dimensional) image showing the extent of the aneurysm from distal ascending aorta up to the supra celiac thoracic aorta. (b) Postoperative computed tomography angiogram volume rendered (three dimensional) image 2 years post staged hybrid repair showing patent supra aortic pan debranching grafts and two thoracic endovascular aneurysm repair stent grafts. Also, the right common iliac artery had to be stented due to 60% stenosis to permit passage of device|
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Choice of debranching procedure
The widely used Ishimaru's classification was adopted to decide the choice of supra-aortic vessel debranching [Table 2]. When arch involvement was total and subsequent stent-graft deployment mandated at Zone 0 coverage, total debranching was done gaining access to ascending aorta via sternotomy, initially exposing common carotid arteries in the neck and left subclavian artery (LSA) in supraclavicular fossa. The right lobe of the thymus was excised along with the sternal origin of strap muscles to provide space and bed for prosthetic graft out of thorax into the neck. Thereafter, neuroprotective measures, namely methylprednisolone (20 mg/body weight) and thiopentone 1 mg/kg along with 1.5 mg/kg of unfractionated heparin were administered intravenously. An inverted 14/7 mm bifurcated coated polyester graft or 10 mm graft with presutured 8 mm side branch graft was used to perform a bypass from proximal ascending aorta to the carotid arteries [Figure 2]. Whenever Stanford dissection was treated in acute setting, partial cardiopulmonary bypass was utilized so as to offload circulation to avoid ascending aortic injury, while the same was partially exteriorized within Satinsky clamp for proximal anastomosis. Intravenous (IV) protamine at 50% of heparin dose administered was used for a reversal at the end of the procedure.
|Figure 2: Proximal anastomosis of inverted bifurcated Dacron graft onto ascending aorta after application of Lemole side-biting vascular clamp|
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In patients in whom Zone 1 coverage seemed appropriate, the debranching of the left common carotid artery was achieved with carotid–carotid bypass across the neck (necklace graft) through a subfascial pre-tracheal tunnel, thereby avoiding the need for sternotomy [Figure 3]. Similarly with Zone 2 coverage, a left carotid-subclavian bypass was performed, although only in rare situations where sufficient (>2 cm) distal was available beyond the left carotid artery. 7/8 mm coated polyester graft was used for these procedures.
|Figure 3: (a) Computed tomography angiogram volume-rendered (three-dimensional) image in a 60-year-old hypertensive patient showing acute Stanford B aortic dissection with flap abutting the base of left subclavian artery. (b) Computed tomography angiogram coronal maximum intensity projection image of the same patient showing massive left hemothorax due to aortic rupture. (c) Computed tomography angiogram volume-rendered (three-dimensional) image on 7th postoperative day following synchronous hybrid repair (carotid-carotid bypass and Zone 1 stent-graft deployment) showing patent bypass, satisfactory aortic remodeling and retrograde filling of left subclavian artery. (d) Postoperative chest radiograph following graded hemothorax drainage showing cleared up lung fields|
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In the cardiovascular ICU, the patient was ventilated and monitored keeping controlled blood pressure of 110–120 mmHg and assessed using neuromonitoring protocol for consciousness and limb movements. Overnight ventilation was continued and the patient shifted to cath lab for stent-graft deployment the next morning.
In the cath lab, femoral artery cut down was done on the right side, and a percutaneous sheath placement in the left femoral artery. Occasionally, right radial/brachial percutaneous access was utilized for catheter placement into the arch for intra-procedural angiography and to guide deployment. IV unfractionated heparin (1 mg/kg) was administered at this stage and via the right femoral arteriotomy, the stent-graft delivery system was taken up over a super-stiff guidewire parked in the ascending aorta and positioned at the intended site of placement. Induced hypotension to 65–70 mmHg was achieved using IV nitroglycerine and of late either by IV adenosine or transvenous rapid pacing to 240/min to obtain desired hemodynamic control for stable and precise deployment of stent-graft. For deployment, the standard protocol was adhered to as per the instructions for use. Ballooning of seal zones was employed, if necessary, but particularly avoided in the setting of dissection/trauma. Check angiography was done both at arch and descending aorta including viscerorenal segment to confirm intact blood flow. Femoral arteriotomy as well as groin wound was then repaired.
All patients were followed up regularly postoperatively with contrast CT aortography done either prior to or within 1 month of dismissal from hospital to assess the integrity of the repair. A chest radiograph was also taken to record baseline stent position. Follow-up protocol included clinical evaluation at 3 and 6 months and yearly thereafter. At 1–2-year follow-up, a surveillance contrast imaging was done [Figure 4]. If no concerning findings (change in stent position, new-onset endoleak, increase in aneurysm size) were noted on the study, further follow-up was limited to clinical evaluation and chest radiographs (PA and lateral views) to avoid radiation and contrast exposure to the patient.
|Figure 4: (a) Computed tomography angiogram volume-rendered (three-dimensional) image showing residual aortic arch and descending thoracic aorta dissection with aneurysmal degeneration following prior graft replacement of ascending aorta for type A aortic dissection. (b) Computed tomography angiogram Volume-rendered (three-dimensional) image at 1 year follow-up showing patent bypass grafts, significantly re-modelled aorta, and near-total thrombosis of false lumen.|
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| Results|| |
A total of 75 patients underwent hybrid arch repair by the principal surgeon between September 2007 and November 2020, after excluding one 72-year-old lady from this cohort who developed dense hemiplegia following total debranching and so mutually decided against aneurysm repair per se. Age of the male preponderant cohort with a sex ratio of 11:1 ranged from 22 to 82 years with a mean of 70. Demographic details are summarized in [Table 3].
Sixty-seven (89.3%) procedures were staged. Eight (10.7%) patients were under synchronous hybrid procedure on account of being emergency interventions.
Technical success was achieved in 97.3% (73/75) with unfavorable stent-graft deployment occurring in 2 patients. 30-day/inhospital mortality occurred in 7 (9.3%) out of 75 patients [Table 4], 5 in aneurysm group and 2 in dissection group. Causes leading to mortality were COPD and respiratory failure in one, myocardial infarction in one, disseminated intravascular coagulation in one, one sudden death at home 20 days post aortic and esophageal stenting for primary aorto-esophageal fistula, and one patient succumbing to neurological complications following extension of proximal sealing zone and chimney stent to the innominate artery for type IA endoleak. In the dissection group, one patient succumbed due to respiratory insufficiency with pneumonia and the other due to mesenteric malperfusion.
Perioperative major morbidity was encountered in 11 (14.6%) patients [Table 4]. Major stroke occurred in 2 (2.6%) patients. One patient developed a significant neurologic deficit, so the stent graft procedure was done 2 months later after neurological recovery. Another elderly lady developed a massive hemorrhagic stroke with only partial neurological recovery. None of the patients developed paraparesis/paraplegia. Five (6.6%) patients whose serum creatinine was mildly elevated preoperatively developed transient worsening after procedure out of which one patient whose preoperative serum creatinine was 2.2 mg% went on to requiring maintenance hemodialysis. Four (5.3%) patients developed neck hematoma requiring re-exploration and evacuation.
Up to 10 years following the procedure, two patients were lost to follow-up. During the follow-up period, a 75-year-old gentleman with symptomatic arch aneurysm succumbed at home from esophageal rupture despite aortic and esophageal stenting after 5 weeks. Three patients succumbed to massive hemoptysis beyond 2 years of the procedure despite follow-up CT angiography showing intact repair, reduction in aneurysm size, and normal lung fields. The patient who became dialysis dependent died after 4 years from non-aneurysmal cause.
In the Stanford B dissection group, a 58-year-old hypertensive male patient who had minor CAD (50% left anterior descending stenosis) developed sudden cardiac death 1 year after hybrid repair. Chest CT aortography 2 weeks before the sudden fatal event had shown intact repair status with patent ascending aorto-bicarotid bypass and stent-graft deployed at Zone “0” with no evidence of endoleak. Another 60-year-old priest had an unexplained sudden death after 8 months of repair in spite of being asymptomatic and surveillance CT aortography showed positive aortic remodeling.
| Discussion|| |
Arch of aorta constitutes a critical domain of circulatory system that provides blood supply to the brain and upper limbs and further forms inflow to the rest of our body, particularly spinal cord, viscerorenal, and lower limb circulations. Arch is afflicted with degenerative aneurysm, aortic dissection, and trauma and appropriate management is vital to save life and preserve organ function. Initial attempts to surgically repair the disorders of aortic arch were fraught with high mortality till Randall Griepp of Stanford University published his experience with total circulatory arrest using profound hypothermia. Thereafter, adjuvants like antegrade cerebral perfusion further improved surgical success as also techniques with cardiopulmonary bypass with mild hypothermia.
The landmark minimally invasive endovascular aneurysm repair (EVAR) popularized by Juan Parodi and Michael Dake in the 1990s was a game-changer in surgical therapy for aortic pathologies. Fenestrated EVAR (FEVAR) and chimney EVAR (ChEVAR) are safe, although complex total endovascular solutions, and require high level catheter skills and interventional experience.,, Nevertheless, we chose a combination of open debranching of appropriate brachiocephalic arteries combined with aortic stent grafting providing durable and cost-effective therapeutic option mixing best of both conventional and minimally invasive.
In our cohort of 75 patients, technical success was 97.3%. Endovascular mishap happened in 2 patients. First was fatal mesenteric malperfusion in a case of TBAD with a spiral intimal flap. In the second patient following hemi-arch debranching for distal aortic aneurysm in a 65-year-old lady, innominate artery got accidentally jailed, while stent-graft was deployed, but the patient could be saved by expeditious ascending aorta to necklace graft bypass, induced pentothal coma, and supportive measures. Diverse causes resulted in inhospital/30-day mortality in 7 patients (7/75 = 9.3%). The elderly cohort with various degrees of compromised systems is a high-risk group for major vascular surgical undertakings. Most published literature on hybrid arch repairs has estimated 30-day mortality rates of between 7% and 12%.,,
Perioperative morbidities in our series were acceptable with neurological complications being the dominant causes, understandably while working in the perilous domain of the aortic arch and cerebral circulation. Two patients suffered adverse cerebrovascular events but eventually leading to minor disability. A systematic review published by Rudarakanchana et al. reported stroke risk of up to 15% and paraplegia risk of up to 6%.
A recurring cause of late mortality at 2–5 years in three essentially asymptomatic patients in spite of satisfactory findings of chest CT aortogram was massive hemoptysis. These probably may have occurred due to stent-graft infringement onto the bronchial tree which could have been due to liberal device oversizing around 20%. Similar delayed complications of late aortobronchial fistulation where the aorta is in very close relation to the left main bronchus have also been reported in a recent study. Thereafter, our practice was modified to oversizing of around 8%–10% in aneurysm and 5%–8% in dissection/traumatic injury. This event has not occurred in the last 6 years and we believe that optimal oversizing has helped prevent these fatal sequelae without adversely affecting the adequacy of proximal and distal seal.
Our approach to staged debranching and TEVAR in elective procedures was based on two patients who developed adverse cerebral events following the former. As both the procedures have the potential for embolic cerebrovascular events, a double neurological hit could have more detrimental consequences. Hence only in the situation of threatened or actual rupture, the synchronous procedure was adopted [Figure 5]. Other surgeons have also shared a similar sentiment to ours.
|Figure 5: (a) Computed tomography angiogram (coronal section) showing large distal arch aneurysm with contained rupture. (b) Postoperative computed tomography angiogram volume rendered (three dimensional) image showing synchronous bi carotid debranching with Zone 0 stent graft deployment|
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The key to success of Hybrid repair is in preventing Type I endoleak, IA in particular. A high rate of re-interventions has often been reported due to this issue. Therefore, we chose to keep an extended proximal sealing zone of 3 cm so as to have desired sealing with the stent-graft poised in a horizontal lie and avoid migration. Retrograde arch dissection in cases of Stanford B aortic dissection is also a significant late complication with an incidence of 2.5% reported in a large series., We also strongly believe that our approach of extending the proximal seal as described has helped us negate this disastrous sequel. It also helps us accomplish most cases without the need for additional extension stent-graft to tackle inadequate proximal sealing. Nevertheless, this comes with a prize of aggressive debranching, either pan-arch or hemi-arch in most cases. This is the reason why we have chosen Zone 2 deployment in only two cases.
The jury is still out with regard to approach on LSA revascularization. We have chosen a high selective approach to the same, not revascularizing LSA as a routine. Aortic dissection, extensive descending thoracic aorta coverage, previous abdominal aortic aneurysm repair, and diminutive right vertebral artery are mandatory reasons to revascularize LSA. These are determinants of spinal cord dysfunction if antegrade LSA perfusion is not preserved. Left upper limb ischemia is an extremely rare sequel and we have never faced need to revascularize for ischemic symptoms, mostly because of reversal of vertebral artery flow to left upper limb along with other collateral pathways. Routine revascularization of LSA could in fact be associated with higher rates of perioperative morbidity. On a unique occasion, we have used distalized LSA from mid descending thoracic aorta to revascularize sole right common carotid artery in a patient with ruptured arch and innominate artery aneurysm in the presence of occluded left carotid [Figure 6].
|Figure 6: (a) Computed tomography angiogram (sagittal section) showing ruptured aortic arch aneurysm with innominate aneurysm and occluded left common carotid artery with a retrosternal rupture hematoma (yellow arrow). (b) Post-procedure computed tomography angiogram volume-rendered (three-dimensional) image showing distalised left subclavian A and left subclavian A to right common carotid artery bypass and excluded aneurysm by stent-graft in Zone 0 and Amplatzer plug occlusion of the innominate artery|
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Subsequent to the first-year follow-up including CT aortogram, our policy has been clinical evaluation along with chest X-ray PA and left lateral views. Makaloski et al. have also proposed use of chest radiography in their surveillance protocol following TEVAR. Further CT aortogram would be performed only in symptomatic patients, if stent malposition was noticed on X-rays or once after 4–5 years for long-term surveillance. This protocol is adopted to avoid risks from repeated radiation and contrast exposures, contrast-induced nephropathy being a real risk in the elderly with especially those with compromised renal function.
- Staged debranching and TEVAR as a matter of extreme caution in elective setting
- Proximal landing zone at Zone 0 or Zone 1 to be cautious to avoid Type 1 A endoleak and obtain 3 cm proximal seal with a horizontal lie of stent graft in mid arch
- Oversizing of 8%–10% in aneurysm and 5%–8% in dissection and trauma.
In summary, aortic arch is a critical domain of thoracic aorta afflicted by diverse pathologies and requires an individualized therapeutic approach, options being open repair under cardiopulmonary bypass or deep hypothermic circulatory arrest, total endovascular repair, or hybrid repair. Hybrid procedure in our experience have shown to be relatively safe, cost effective and durable principal therapeutic option for aortic arch pathologies.
The authors wish to express their gratitude to the Director of Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, and the Medical Superintendent of Sree Uthradom Tirunal Hospital, Pattom, Thiruvananthapuram, for their encouragement and permission to publish this article on hybrid aortic arch repair.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4]