Minimally Invasive Hybrid Aortic Arch Repair
Oleg Orlov, Vishal Shah, DO, Robert Meisner, MD, Cithia Orlov, Matthew Thomas, MD, Manabu Takebe, Konstadinos Plestis, MD.
Lankenau Medical Center, Wynnewood, PA, USA.
OBJECTIVE: Despite advances in surgical techniques, traditional open surgical repair for type B dissections is high-risk. Hybrid surgery with open surgical arch debranching when necessary and thoracic endovascular aortic repair has been recently proposed as a safe alternative. We present a patient who developed recurrent symptoms two months after acute type B dissection and underwent a successful minimally invasive hybrid aortic arch and descending aorta repair.
METHODS: A 55-year-old male presented with severe recurrent chest and back pain 2 months after type B aortic dissection. Computed tomography (CT) scan of the chest demonstrated increasing size of the false lumen, compression of the true lumen and a descending thoracic aortic aneurysm measuring greater than 4 cm. An upper mini-sternotomy extending to the right 4th intercostal space was performed. A 12 x 8 x 8 trifurcation graft (TG) was utilized for aortic arch reconstruction. The main limb of the TG was anastomosed to the ascending aorta. The brachiocephalic and left carotid vessels were transected 1 cm beyond their origins and serially anastomosed with 5-0 polypropylene to the individual limbs of the TG. A left infraclavicular incision was performed to isolate the left subclavian artery. The 3rd limb of the TG was anastomosed to the left subclavian artery. Bilateral femoral percutaneous access was obtained. Next, a 38 x 34 x 250 mm Relay endograft (Bolton Medical, Sunrise, FL, USA) was deployed in Zone 0. The graft was positioned just distal to the takeoff of the TG extending to the mid descending aorta. The patient was discharged on POD #6 without complications.
RESULTS: Post-procedure completion aortogram demonstrated no endoleak and intravascular ultrasound (IVUS) noted the true lumen to be convex. One-month follow-up CT scan showed the endograft in correct position without endoleak and patent bypass grafts.
CONCLUSIONS: A minimally invasive hybrid aortic arch repair provided a successful outcome in a patient with a complex subacute type B dissection and descending thoracic aortic aneurysm. The repair allowed for a small incision and avoided cardiopulmonary bypass and circulatory arrest, while the use of a TG allowed for simplification of arch vessel anastomoses.
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