P235. Optimizing Aortic Coverage with Zone 2 Arch Replacement and a Short-Stent Cuff: The "Buff Cuff" Procedure
Presented During: POD Abstracts (Available for viewing in the exhibit hall for the duration of the meeting)
University of Colorado Anschutz
Denver, CO
United States - Contact Me
Adam Carroll is a current PGY-3 surgical resident at the University of Colorado. Adam attended medical school at the University of Colorado and has been involved in research with the cardiothoracic surgery department throughout medical school and residency. He has interest specifically in endovascular and transcatheter aortic interventions, as well as neurologic outcomes in aortic research. He is currently in the aortic surgery research labaratory in the Department of Cardiothoracic Surgery at the University of Colorado. He plans to pursue a career in cardiothoracic surgery following his general surgery residency.
Thursday, April 25, 2024: 5:38 PM - 7:00 PM
Sheraton Times Square
Room: Central Park
Description
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.
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
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.
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
Presentation Duration
PODS will be on display in the exhibit hall for the duration of the meeting during exhibit hall hours. PODS will also be available for viewing on the meeting website. There is no formal presentation associated with your POD, but we encourage you to visit the PODS area during breaks to connect with those viewing.