Retrograde in-situ fenestration technique for a post-coronary arterial bypass grafting patient using a high-flow shunting technique

P0288 

Case Video Submission 

Yoshiaki Saito (1), Kenyu Murata (1), Yuki Imamura (1), Rin Itokawa (1), Masahito Minakawa (1)

(1) Hirosaki University School of Medicine, Hirosaki, NA

Yoshiaki Saito    -  Contact Me
Hirosaki University School of Medicine

Kenyu Murata    -  Contact Me
Hirosaki University School of Medicine

Yuki Imamura    -  Contact Me
Hirosaki University School of Medicine

Rin Itokawa    -  Contact Me
Hirosaki University School of Medicine

Masahito Minakawa    -  Contact Me
Hirosaki University School of Medicine

Yoshiaki Saito    -  Contact Me
N/A

Objective: In-situ fenestration technique for Zone 1 TEVAR can be an excellent alternative to open surgical repair. However, the surgical risk can be high in patients with a history of coronary arterial grafting (CABG) due to left internal mammary artery (LIMA) graft ischemia during the fenestration procedure. The two-debranching procedure can be an option, although insufficient brain perfusion and cosmetic problems remain. An extracorporeal circuit may be employed, though an embolic event can occur. We employed left subclavian-femoral arterial shunting using a high-flow vascular sheath to minimize the risk of LIMA graft ischemia during Zone 1 in-situ fenestration TEVAR.

Case video summary
The patient was a 70-year-old male with a history of CABG and abdominal aortic replacement. LIMA was anastomosed to the left anterior descending artery. The computed tomography showed a thoracic aortic aneurysm lying from the aortic arch to the descending thoracic aorta with a maximum diameter of 60 mm. Zone 1 left common carotid artery (LCCA) in-situ fenestration TEVAR was planned. LCCA – left subclavian arterial bypass was performed prior to the stentgraft placement. A 6Fr high-flow vascular sheath was inserted into the neck bypass graft and was connected to the 22 Fr Dryseal sheath, which was inserted from the right femoral artery for the shunting. A 40mm-20cm main Gore cTAG was deployed from Zone 1. The needle puncture for the left common carotid in-situ fenestration was difficult because of the shallow angle between LCCA and the aorta(18°). LCCA was finally reconstructed (the time from Zone 1 landing to successful puncture was 16.5 minutes), and there was no ST-segment change or circulatory instability during the puncture. There was no myocardial ischemia and stroke, and no endoleak was shown in the postoperative CT scan.

Conclusion
The left subclavian-femoral arterial shunting using a high-flow vascular sheath was a reliable technique for safely performing Zone 1 in-situ fenestration TEVAR in a patient with a history of CABG.

Aortic Arch