The Application of Aortic Debranching to Facilitate Zone 0 Coverage With Thoracic Branched Endograft
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0327
Submission Type:
Abstract Submission
Authors:
Adam Carroll (1), Donald Jacobs (1), T. Brett Reece (1), Muhammad Aftab (1)
Institutions:
(1) University of Colorado Anschutz, Denver, CO
Submitting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Co-Author(s):
Donald Jacobs
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University of Colorado Anschutz
University of Colorado Anschutz
*T. Brett Reece
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University of Colorado Anschutz
University of Colorado Anschutz
*Muhammad Aftab
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University of Colorado Anschutz
University of Colorado Anschutz
Presenting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Abstract:
Objective:
Thoracic endovascular aortic repair (TEVAR) is well established for zone 2 aortic arch coverage, with maintenance of left subclavian perfusion through collateral vessels, or open or endovascular revascularization. Thoracic branched endografts (TBE) have been applied to zone 2 arch repair, allowing for subclavian revascularization with a comparable safety profile and a decreased length of stay. Proximal to zone 2, TBE has seen very limited application due to the high risk of neurologic complications. We discuss two cases of patients who underwent aortic debranching and subsequent zone 0 TBE.
Methods:
We discuss two patients with a history of previous type A aortic dissection and remote repair requiring intervention after further degeneration. We discuss presentation, operative details, and hospital course. Reconstruction of patient aortic pathology was performed using Slicer 3D software.
Results:
Four years prior, patient 1 underwent aortic valve resuspension and ascending aortic repair for his type A dissection. Observation of his pathology demonstrated aneurysmal degeneration of his aortic arch and descending thoracic aorta (Figure 1; 1A). He was admitted for elective aortic debranching and TBE. He underwent right carotid to left carotid to subclavian, carotid-carotid, and right carotid to subclavian bypass, right vertebral to carotid transposition, and ligation of the bilateral carotids and right subclavian artery (Figure 1; 1B). He developed right vocal cord paresis post-operatively, which resolved without intervention. He also developed a left neck chyle leak, and he was discharged on hospital day (HD) 10 with a left neck drain in place. He subsequently underwent staged TBE with proximal extension to the ascending aorta and stenting of the left subclavian without complication (Figure 1; 1C). The patient was discharged on HD 2 on aspirin, in addition to oral anticoagulation for history of atrial fibrillation.
Two years prior, patient 2 had a hemiarch replacement for type A dissection. She presented with symptoms of hemoptysis, with concern for contained rupture with aorto-pulmonary fistula, in addition to descending thoracic aneurysmal degeneration with dissection extending into the proximal left common carotid and subclavian arteries (Figure 1; 2A). She underwent aortic debranching with right to left carotid bypass, left carotid to subclavian bypass, with ligation of the left common carotid artery and amplatzer plug of the left subclavian artery (Figure 1; 2B). On hospital day (HD) two, the patient underwent thoracic branched endograft with stenting of the innominate artery (Figure 1; 2C). The procedure was uncomplicated, and the patient was started on aspirin monotherapy. Hospital course was prolonged due to left vocal cord paresis related to aortic debranching and resulting poor oral intake, which was treated with vocal cord injection and placement of a percutaneous endoscopic gastrostomy tube. The patient was discharged on HD 33 on aspirin and oral anticoagulation, without significant neurologic deficits.
Conclusion:
With careful patient selection at dedicated aortic centers, zone 0 TBE can be safely performed. Further experience is needed to mitigate the risks related to extensive aortic debranching.
Thoracic endovascular aortic repair (TEVAR) is well established for zone 2 aortic arch coverage, with maintenance of left subclavian perfusion through collateral vessels, or open or endovascular revascularization. Thoracic branched endografts (TBE) have been applied to zone 2 arch repair, allowing for subclavian revascularization with a comparable safety profile and a decreased length of stay. Proximal to zone 2, TBE has seen very limited application due to the high risk of neurologic complications. We discuss two cases of patients who underwent aortic debranching and subsequent zone 0 TBE.
Methods:
We discuss two patients with a history of previous type A aortic dissection and remote repair requiring intervention after further degeneration. We discuss presentation, operative details, and hospital course. Reconstruction of patient aortic pathology was performed using Slicer 3D software.
Results:
Four years prior, patient 1 underwent aortic valve resuspension and ascending aortic repair for his type A dissection. Observation of his pathology demonstrated aneurysmal degeneration of his aortic arch and descending thoracic aorta (Figure 1; 1A). He was admitted for elective aortic debranching and TBE. He underwent right carotid to left carotid to subclavian, carotid-carotid, and right carotid to subclavian bypass, right vertebral to carotid transposition, and ligation of the bilateral carotids and right subclavian artery (Figure 1; 1B). He developed right vocal cord paresis post-operatively, which resolved without intervention. He also developed a left neck chyle leak, and he was discharged on hospital day (HD) 10 with a left neck drain in place. He subsequently underwent staged TBE with proximal extension to the ascending aorta and stenting of the left subclavian without complication (Figure 1; 1C). The patient was discharged on HD 2 on aspirin, in addition to oral anticoagulation for history of atrial fibrillation.
Two years prior, patient 2 had a hemiarch replacement for type A dissection. She presented with symptoms of hemoptysis, with concern for contained rupture with aorto-pulmonary fistula, in addition to descending thoracic aneurysmal degeneration with dissection extending into the proximal left common carotid and subclavian arteries (Figure 1; 2A). She underwent aortic debranching with right to left carotid bypass, left carotid to subclavian bypass, with ligation of the left common carotid artery and amplatzer plug of the left subclavian artery (Figure 1; 2B). On hospital day (HD) two, the patient underwent thoracic branched endograft with stenting of the innominate artery (Figure 1; 2C). The procedure was uncomplicated, and the patient was started on aspirin monotherapy. Hospital course was prolonged due to left vocal cord paresis related to aortic debranching and resulting poor oral intake, which was treated with vocal cord injection and placement of a percutaneous endoscopic gastrostomy tube. The patient was discharged on HD 33 on aspirin and oral anticoagulation, without significant neurologic deficits.
Conclusion:
With careful patient selection at dedicated aortic centers, zone 0 TBE can be safely performed. Further experience is needed to mitigate the risks related to extensive aortic debranching.
Aortic Symposium:
Endoluminal Prostheses
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