Individualized hybrid approach for treatment of a giant intrathoracic left subclavian artery aneurysm utilizing TEVAR and open supra aortic debranching
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0171
Submission Type:
Abstract Submission
Authors:
Peter Donndorf (1), Clemens Schafmayer (2), Justus Gross (2)
Institutions:
(1) Department of General-, Visceral-, Thoracic-, Vascular- and Transplant Surgery, Rostock, (2) Department of General-, Visceral-, Thoracic-, Vascular- and Transplant Surgery, Rostock, NA
Submitting Author:
Peter Donndorf
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Department of General-, Visceral-, Thoracic-, Vascular- and Transplant Surgery
Department of General-, Visceral-, Thoracic-, Vascular- and Transplant Surgery
Co-Author(s):
Clemens Schafmayer
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Department of General-, Visceral-, Thoracic-, Vascular- and Transplant Surgery
Department of General-, Visceral-, Thoracic-, Vascular- and Transplant Surgery
Justus Gross
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Department of General-, Visceral-, Thoracic-, Vascular- and Transplant Surgery
Department of General-, Visceral-, Thoracic-, Vascular- and Transplant Surgery
Presenting Author:
Peter Donndorf
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Abstract:
A 63year old female was referred to our department with a pulsatile left supra-clavicular tumor for further diagnostic and treatment. Medical history included Marfan syndrom, replacement of the aortic valve and the ascending aorta well as open thoracoabdominal aortic replacement.
Methods:
Contrast enhanced Computed Tomography (CT) revealed a giant aneurysm of the proximal and middle left subclavian artery with a maximum diameter of 5.5cm. Due to the proximal extent of the aneurysm open surgical repair would have required a re-re sternotomy approach which was considered technically very high risk.
Likewise complete endovascular exclosure was deemed uncertain due to the large size and proximal extent of the aneurysm without an adequate proximal landing zone.
We opted therefore for an alternative indirect hybrid approach combining a thoracic aortic stent graft (TEVAR) covering the aortic origin left subclavian artery and left carotid-subclavian bypass as well as transposition of the left vertebral artery into the left common carotid artery for aneurysm exclusion. First a 28x40mm Relay Pro aortic stent graft (Terumo Aortic, UK) was implanted in the distal aortic arch for proximal closure of the aneurysm. Next the left common carotid as well as the left vertebral artery were exposed via a left cervical incision and transposition of the left vertebral artery into the left common carotid artery was performed, facilitating save ligation of the proximal left vertebral artery arising from the aneurysm. Finally the distal left subclavian artery was exposed via a separate infraclavicular incision. A 8 mm Dacron prosthesis was anastomosed in an end-to-end fashion to the distal subclavian artery creating a carotid-subclavian bypass. The distal end of the mid left subclavian artery was ligated thereby completing aneurysm exclusion.
Results:
The patient had an uneventful postoperative course and was discharged at post-operative day six. A control CT prior hospital discharge showed sufficient exclosure of the subclavian aneurysm and unobstructed perfusion of the transposed left vertebral artery as well as the distal left subclavian artery.
Conclusion:
Our case demonstrates that combining established endovascular and open surgical procedures facilitates safe and efficient treatment facilitates the safe and efficient treatment even of anatomically challenging vascular pathology such as large intrathoracic subclavian artery aneurysms. Although endovascular procedures should always be considered carefully when treating aneurysmal disease in Marfan patients, we believe that in case like ours with a high technical risk of complete open surgical repair the use of a routine endovascular procedure like TEVAR in combination with a tailored open surgical part for a less invasive and still reliable aneurysm treatment is justified.
Methods:
Contrast enhanced Computed Tomography (CT) revealed a giant aneurysm of the proximal and middle left subclavian artery with a maximum diameter of 5.5cm. Due to the proximal extent of the aneurysm open surgical repair would have required a re-re sternotomy approach which was considered technically very high risk.
Likewise complete endovascular exclosure was deemed uncertain due to the large size and proximal extent of the aneurysm without an adequate proximal landing zone.
We opted therefore for an alternative indirect hybrid approach combining a thoracic aortic stent graft (TEVAR) covering the aortic origin left subclavian artery and left carotid-subclavian bypass as well as transposition of the left vertebral artery into the left common carotid artery for aneurysm exclusion. First a 28x40mm Relay Pro aortic stent graft (Terumo Aortic, UK) was implanted in the distal aortic arch for proximal closure of the aneurysm. Next the left common carotid as well as the left vertebral artery were exposed via a left cervical incision and transposition of the left vertebral artery into the left common carotid artery was performed, facilitating save ligation of the proximal left vertebral artery arising from the aneurysm. Finally the distal left subclavian artery was exposed via a separate infraclavicular incision. A 8 mm Dacron prosthesis was anastomosed in an end-to-end fashion to the distal subclavian artery creating a carotid-subclavian bypass. The distal end of the mid left subclavian artery was ligated thereby completing aneurysm exclusion.
Results:
The patient had an uneventful postoperative course and was discharged at post-operative day six. A control CT prior hospital discharge showed sufficient exclosure of the subclavian aneurysm and unobstructed perfusion of the transposed left vertebral artery as well as the distal left subclavian artery.
Conclusion:
Our case demonstrates that combining established endovascular and open surgical procedures facilitates safe and efficient treatment facilitates the safe and efficient treatment even of anatomically challenging vascular pathology such as large intrathoracic subclavian artery aneurysms. Although endovascular procedures should always be considered carefully when treating aneurysmal disease in Marfan patients, we believe that in case like ours with a high technical risk of complete open surgical repair the use of a routine endovascular procedure like TEVAR in combination with a tailored open surgical part for a less invasive and still reliable aneurysm treatment is justified.
Aortic Symposium:
Endoluminal Prostheses
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