Challenging Hybrid Repair Of Non-A-non-B Aortic Dissection In Patient With Right Sided Angulated Aortic Arch
yama Shoaib haqzad, Mohamed Shoeib, Mohamed Sherif, Massimo Cappoccia, Ahmed Nassef, Sapna Puppala, David Shaw, Paul Walker, Pankaj Kaul, Walid ElMahdy.
Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.
BACKGROUND:Patients with right sided aortic arch have a predisposition to develop aortic dissection (AD). The term non-A-non-B aortic dissection was recently updated in the ESVS/EACTS consensus, defined as type B dissection with involvement of the aortic arch. Evidence regarding optimal management is limited. This is a challenging case that was managed successfully using hybrid technique with the involvement of the aortovascular multidisciplinary team(MDT).METHODS:70-year-old lady, with history of hypertension and right sided, angulated (gothic) aortic arch with descending thoracic aortic aneurysm(under surveillance),presented acutely with non-A-non-B aortic dissection, measuring 64mm. The tear just distal to left subclavian origin extending to diaphragmatic hiatus, with retrograde extension to aortic arch and dilated ascending aorta. Anomalous origins of supra aortic vessels, significant angulation and calcification of the aortic arch at the origin of subclavian arteries.Aortovascular MDT concluded non feasibility of endovascular options due to significant aortic angulation, absence of suitable landing zone with high risk of retrograde aortic dissection. Moreover, Frozen Elephant Trunk(FET) was not deemed an option due to risk of failure of expansion of FET stent (weak radial force)in gothic angled arch. Hybrid repair was agreed to be the best option.RESULTS:Joint procedure in Hybrid theatre involving cardiac surgeons, vascular surgeons and vascular interventional radiologists. She underwent ascending aorta replacement, aortic arch debranching with extra-anatomical bypass of both subclavian arteries, and "branch first" technique for both carotid arteries + direct antegrade aortic arch/descending aortic TEVAR(GORE TAG Conformable Stent)connected to aortic graft as a hybrid elephant trunk. The patient had uneventful endovascular coiling of proximal left subclavian artery and TEVAR extension of the descending aorta same admission. Patient survived without bleeding, stroke, paraplegia or malperfusion. Transient vocal cord palsy recovered before her discharge.CONCLUSIONS:None A none B AD involving right sided aorta is an extremely rare condition , with limited evidence for optimal management.Aortvascular MDTs with the involvement of cardiac/vascular surgeons, vascular interventionist and anaesthetists allow complex rare aortic cases to be assessed with consideration of relative risks and benefits of various approaches. Hybrid approach for complex aortic pathologies can thus offer safe management strategies, especially in cases like this with challenging anatomy.
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