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Hybrid repair for complex aortic arch disease: How to prevent cerebrovascular complication in total debranching TEVAR
Tomohiro Mizuno, Dr., Tsuyoshi Hachimaru, Dr, Keishi Oi, Dr., Daiju Watanabe, Dr., Hidehito Kuroki, Dr., Tatsuki Fujiwara, Dr., Shogo Sakurai, Dr., Kenji Sakai, Dr., Hirokuni Arai, Dr..
Tokyo Medical and Dental University, Graduate school of Medicine, Tokyo, Japan.

Endovascular repair for aortic arch disease has been dramatically progressing in the last decade, and aortic arch disease can be now treated without cardiopulmonary bypass (CPB). However, there remain some technical problems such as cerebrovascular emboli and aortic dissection.
We performed 6 total debranching thoracic endovascular aortic repair (TEVAR) to zone 0 for complex aortic arch disease in the last one year. We always place axillo-axillar (A-A) bypass before reconstructing the arch vessels because A-A bypass can prevent cerebral emboli and ischemia at the time of reconstruction. Our surgical procedure was as follows: 1. Axillo-axillar (A-A) bypass is placed. 2. The proximal anastomosis of the debrancing grafts is placed at the ascending aorta as proximal as possible to secure the landing zone. 3. The brachiocepharic artery is reconstructed by direct clamping. 4. The left carotid artery is reconstructed. 5. The left subclavian artery is ligated. 6. The stent graft is deployed. When CPB is needed, A-A bypass graft is used for arterial cannulation.
Mean age was 75.0 years old (63 to 82). There were 3 true aneurisms, 2 subacute aortic dissections with an ulcer-like projection and 1 chronic aortic dissection. Three patients had ischemic heart disease. Total debranching TEVAR without CPB was performed in 3 patients. CPB was used in 3 patients because of the replacement of the ascending aorta and the aortic valve (1) and the difficulty of the aortic partial clamp (2). Coronary artery bypass grafting was performed in 2 patients. There was no endoleak and no neurologic complication. Localized aortic dissection was recognized at the proximal anastomotic site in 1 patient, and the ascending aorta was replaced 7 days after total debrancing TEVAR. Although the duration of follow-up was still short (4-16 months), all patients were survived and there was no aorta-related complication.
Total debranching TEVAR with axillo-axillar bypass is safe and useful to prevent cerebrovascular complication, but there remain some aorta-related complications that should be solved.

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