Open Hybrid Treatment of Complex Thoracic Aortic Aneurism in a High-Risk Octogenarian Patient

P0230 

Case Video Submission 

Anibal Ibanez (1), Patrick Vargo (1), Xiaoying LOU (1), Eric Roselli (1), Faisal Bakaeen (1), Edward Soltesz (1), Michael Tong (1), Shinya Unai (1), Haytham Elgharably (1), Benjamin Kramer (1), Noah Weingarten (1), Francis Caputo (1), Jon Quatromoni (1), Ali Khalifeh (1), Lars Svensson (1), Marijan koprivanac (1)

(1) Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH

Anibal Ibanez    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

Patrick Vargo    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

Xiaoying LOU    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

*Eric Roselli    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

*Faisal Bakaeen    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

*Edward Soltesz    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

*Michael Tong    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

*Shinya Unai    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

♦Haytham Elgharably    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

Benjamin Kramer    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

Noah Weingarten    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

Francis Caputo    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

Jon Quatromoni    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

Ali Khalifeh    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

*Lars Svensson    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

Marijan Koprivanac    -  Contact Me
Cardiovascular Surgery Department, Heart, Vascular and Thoracic Institute, Cleveland Clinic

Anibal Ibanez    -  Contact Me
N/A

Objective: The purpose of this case is to show a successful hybrid approach of the repair of an Ascending-Descending Aneurisms with relatively stable size arch in a high-risk patient. Approach provides efficient, simplified way of dealing with this pathology with minimal exposure to circulatory arrest.
Case Video Summary: The patient is an 83-year-old frail female on two liters of oxygen at home with significant medical history of Atrial Fibrillation, Coronary Artery Disease, Diabetes Mellitus, and obesity. Incidentally, an Ascending-Descending aortic aneurism is found after a total right knee replacement complicated by Deep Vein Thrombosis and Pulmonary Embolism.
CT angiogram showed the ascending and proximal descending aorta with 5.2 cm and 6.2 cm, respectively. Aortic arch of 3.5 cm.
Transthoracic Echocardiogram showed Normal Left and Right ventricular function/size.
Based on our assessment, we planned an Ascending and Total Aortic Arch Replacement, performing a fenestrated Frozen Elephant Trunk with stent to left subclavian and carotid arteries (BSAFER), in an octogenarian and high-risk patient.
Central cannulation is performed. Superior Vena Cava (SVC) is cannulated for retrograde brain perfusion. Head vessels and aortic root are dissected to maximize efficiency and diminish CPB exposure.
Patient is cooled to the level of deep hypothermia for about 30 min. Circulatory arrest is initiated and retrograde brain perfusion started. A 40 mm x 10 cm stent graft is delivered antegrade into the descending aorta under direct vision. Based on tissue quality assessment and arch disease the device is deployed and positioned in zone 1. A 13 mm x 2.5 cm branch vessel stent graft is delivered into the Left Subclavian (LSC) artery. Retrograde perfusion is stopped and antegrade perfusion is started through the innominate and LSC arteries. A 10 mm x 5 cm stent component is deployed into the Left Common Carotid and a Pruitt balloon catheter is placed to continue antegrade brain perfusion. The aortic stent graft is circumferentially sutured to the aortic wall. The suture line is continued behind the innominate artery. Distal anastomosis is done by suturing graft to stent and then as coming closer to innominate artery, transitioned to graft to aorta, leaving innominate orifice open and reimplanted. Proximal anastomosis is done in supracoronary fashion and excluding most of the noncoronary sinus.
A total of 24 minutes of Deep Hypothermic Circulatory Arrest with Retrograde and Antegrade Cerebral Perfusion were needed to repair the Total Arch and FET. Patient is extubated the following day and discharged to skilled nurse facility after 3 weeks. The post-operative CT angiogram showed the surgical graft of the ascending aorta and the arch that continues as a frozen elephant trunk to the level of the mid descending aorta without signs of endoleak or pseudoaneurysm formation.
Conclusions: The clinical importance of this case is to show that there is an efficient and effective treatment of the Ascending-Descending Aneurism in a high-risk patient. Brief time of Circulatory Arrest is a significant factor to take into consideration when we address a complex case in an older higher risk patient. A hybrid approach allows us to treat the whole pathology decreasing the circulatory arrest and overall surgical time and with good outcomes. Currently, our patient is doing well is at home and continues her following-up appointments with positive assessments.

Aortic Arch