International Society For Minimally Invasive Cardiothoracic Surgery

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First Case Of Custom Made Aortic Branch Device Used For Total Endovascular Aortic Arch Repair
Hadley K. Wilson, Mark Farber, Thomas G. Caranasos.
University of North Carolina Hospitals, Chapel Hill, NC, USA.

Objective: Reoperation for aneurysmal dilation of the aortic arch after ascending hemiarch repair for type A dissection occurs in approximately 5% of patients. This typically requires redo open heart surgery with circulatory arrest and is associated with significant morbidity rendering many patients unsuitable for redo open repair owing to their comorbid conditions. Endovascular arch repair is an attractive alternative for patients that develop aneurysmal degeneration of the aortic arch after ascending hemiarch replacement for type A dissection. Methods: We describe the first case of total endovascular aortic arch repair with prefabricated custom branch device reported in the United States. The case involves an 80 yo gentleman with enlarging aneurysmal degeneration of his aortic arch and proximal descending thoracic aorta after ascending hemiarch repair with free-style aortic root replacement for Type A dissection three years earlier complicated by perioperative hemorrhage and delayed sternal closure. His medical history was significant for hypertension, heart failure, metastatic prostate cancer and aortic stenosis. Given his advanced age and comorbidities, the risk of open reoperation was prohibitively high. After discussions between vascular surgery, cardiothoracic surgery and cardiothoracic anesthesia and appropriate preoperative evaluation and imaging, the patient underwent total endovascular repair of the aortic arch and proximal descending thoracic aorta using a three vessel branched arch device. Results: He was extubated in the OR and was in the ICU for one night. He was transferred to the stepdown unit on postoperative day one. He was discharged on postoperative day two with dual antiplatelet therapy. Conclusions: Branch devices are well described for treatment of thoraco-abdominal aortic disease, but this is the first report of a custom manufactured branch device used for total endovascular repair of the aortic arch in the United States. Total endovascular repair of the aortic arch has wide reaching implications for the treatment of aortic disease. Further research is needed to determine long term benefits in patients who are too frail to undergo open surgery, and the utility in lower risk patients as well. Additionally, further research is needed to evaluate the results of endovascular repair for aortic pathologies involving the arch and ascending aorta.

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