Optimizing Aortic Coverage with Zone 2 Arch Replacement and a Short-Stent Cuff: The “Buff Cuff” Procedure
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0235
Submission Type:
Abstract Submission
Authors:
Adam Carroll (1), Michael Kirsch (1), Rafael Malgor (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions:
(1) University of Colorado Anschutz, Denver, CO
Submitting Author:
Adam Carroll
-
Contact Me
University of Colorado Anschutz
University of Colorado Anschutz
Co-Author(s):
Michael Kirsch
-
Contact Me
University of Colorado Anschutz
University of Colorado Anschutz
Rafael Malgor
-
Contact Me
University of Colorado Anschutz
University of Colorado Anschutz
*Muhammad Aftab
-
Contact Me
University of Colorado Anschutz
University of Colorado Anschutz
*T. Brett Reece
-
Contact Me
University of Colorado Anschutz
University of Colorado Anschutz
Presenting Author:
Adam Carroll
-
Contact Me
University of Colorado Anschutz
University of Colorado Anschutz
Abstract:
Objectives:
Although management of extensive aortic aneurysmal disease has greatly improved, further techniques are warranted to optimize stent-graft landing zones. In particular, the stricture created by distal anastomosis in open arch replacement can compromise endovascular aortic extension. We describe a case where a short-stent cuff was placed to create a landing zone for a stent distal to a zone 2 arch anastomosis to facilitate extensive aortic coverage for aneurysmal disease.
Methods:
We discuss the case of a 63-year-old female with a history of prior mechanical Bentall and ascending aorta replacement, and Kommerell's diverticulum with an aberrant right subclavian artery who presented with aortic valve stenosis, as well as arch and descending thoracic aortic aneurysms. Prior to addressing her arch pathology, she underwent robotic ligation of her aberrant right subclavian artery, with transposition to her right common carotid and division of her vascular ring.
Results:
The patient was taken to the operating room to address her stenotic mechanical Bentall and her aneurysmal pathology. Following initiation of cardiopulmonary bypass, the proximal arch, innominate and left common carotid were dissected out. The innominate and left common carotid artery, respectively, were divided and sewn to the distal and proximal side arms of a Spielvogel graft and deaired, restoring cerebral perfusion. Following the initiation of circulatory arrest, the aorta was fashioned to underneath the left common carotid. The remaining aorta was resected to zone 2. Given the extent of her descending pathology, to optimize coverage the Bavaria graft was cut to length with 45mm of soft graft distal to the branch takeoffs, and a small 36x45mm Gore Aortic Extender Endoprosthesis was secured proximally and distally to optimize landing zone. The complex was placed in the true lumen of the aorta, and the marked line of the soft graft, the proximal edge of the stent, and the full thickness of the aortic wall were all sewn together, placing the anastomosis at zone 2 with the end of the stent just proximal to the left subclavian artery takeoff. Circulatory arrest was ended, and the prior stenotic Bentall was addressed. Post-operative course was uncomplicated, and the patient was discharged on day 8.
Three months following, the patient returned to the operating room for endovascular extension to address her descending pathology with a zone 2 thoracic branched endograft. After obtaining access, intravascular ultrasound was used to measure the proximal landing zone, which as planned was just proximal to the left subclavian artery and was 38mm and widely patent. Once appropriately positioned, a 40x15mm thoracic branched endograft was placed, which was extended with placement of an additional 45x15mm Gore cTAG. The left subclavian stent-graft was then deployed. Due to her short and tortuous arch, an additional stent-graft was placed proximal to the left vertebral artery, which remained patent. Convalescence thereafter was uncomplicated, and the patient was discharged on post-operative day 2. At one month follow-up, the patient was doing well, with no concerns on three-month surveillance imaging.
Conclusions
Our novel technique of using a short-stent cuff to optimize endovascular extension was successful and allowed for additional aortic coverage. This technique should be considered in select patients with extensive aortic disease at select aortic centers.
Although management of extensive aortic aneurysmal disease has greatly improved, further techniques are warranted to optimize stent-graft landing zones. In particular, the stricture created by distal anastomosis in open arch replacement can compromise endovascular aortic extension. We describe a case where a short-stent cuff was placed to create a landing zone for a stent distal to a zone 2 arch anastomosis to facilitate extensive aortic coverage for aneurysmal disease.
Methods:
We discuss the case of a 63-year-old female with a history of prior mechanical Bentall and ascending aorta replacement, and Kommerell's diverticulum with an aberrant right subclavian artery who presented with aortic valve stenosis, as well as arch and descending thoracic aortic aneurysms. Prior to addressing her arch pathology, she underwent robotic ligation of her aberrant right subclavian artery, with transposition to her right common carotid and division of her vascular ring.
Results:
The patient was taken to the operating room to address her stenotic mechanical Bentall and her aneurysmal pathology. Following initiation of cardiopulmonary bypass, the proximal arch, innominate and left common carotid were dissected out. The innominate and left common carotid artery, respectively, were divided and sewn to the distal and proximal side arms of a Spielvogel graft and deaired, restoring cerebral perfusion. Following the initiation of circulatory arrest, the aorta was fashioned to underneath the left common carotid. The remaining aorta was resected to zone 2. Given the extent of her descending pathology, to optimize coverage the Bavaria graft was cut to length with 45mm of soft graft distal to the branch takeoffs, and a small 36x45mm Gore Aortic Extender Endoprosthesis was secured proximally and distally to optimize landing zone. The complex was placed in the true lumen of the aorta, and the marked line of the soft graft, the proximal edge of the stent, and the full thickness of the aortic wall were all sewn together, placing the anastomosis at zone 2 with the end of the stent just proximal to the left subclavian artery takeoff. Circulatory arrest was ended, and the prior stenotic Bentall was addressed. Post-operative course was uncomplicated, and the patient was discharged on day 8.
Three months following, the patient returned to the operating room for endovascular extension to address her descending pathology with a zone 2 thoracic branched endograft. After obtaining access, intravascular ultrasound was used to measure the proximal landing zone, which as planned was just proximal to the left subclavian artery and was 38mm and widely patent. Once appropriately positioned, a 40x15mm thoracic branched endograft was placed, which was extended with placement of an additional 45x15mm Gore cTAG. The left subclavian stent-graft was then deployed. Due to her short and tortuous arch, an additional stent-graft was placed proximal to the left vertebral artery, which remained patent. Convalescence thereafter was uncomplicated, and the patient was discharged on post-operative day 2. At one month follow-up, the patient was doing well, with no concerns on three-month surveillance imaging.
Conclusions
Our novel technique of using a short-stent cuff to optimize endovascular extension was successful and allowed for additional aortic coverage. This technique should be considered in select patients with extensive aortic disease at select aortic centers.
Aortic Symposium:
Aortic Arch
Image or Table
