Tevar

Surgical Techniques of Debranching in Hybrid Arch Procedures

Dr. Manoj . PLead Consultant, Aster Cardiac SciencesAster Med city, Kochi.

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Background

• Aortic arch aneurysms present a particular challenge to endovascular repair due to the involvement of supra-aortic vessels and the anatomic curvature of the arch

• A variety of maneuvers have been recommended for thoracic endo grafting to address the landing zone limitations imposed by the arch vessels.

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• Repair of aortic arch aneurysm is technically demanding, requiring complex circulatory management.

• Very large atherosclerotic saccular aneurysms of the arch are grave markers of extensive arch and brachiocephalic atheromatous disease

• Represent high surgical risks for perioperative neurologic complications

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Strategy for Arch Aneurysm

Debranched AEVAR

Arch and distal arch aneurysm

Open Surgery

Anatomical limitations• Proximal neck diameter 34 ~ 37mm, length 20mm diameter 23 ~ 33mm, length 15mm•Character of Aortic wall (ascending aorta)

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• Despite technical and technological improvements, Open repair is associated with high mortality and morbidity mainly due

to DHCA and cerebral ischemia

• Pre-op comorbidities Poor outcome

• For patients unfit for conventional surgery , hybrid approach of aortic arch debranching with re-routing of supra aortic trunk and exclusion of pathological portion of aortic arch employing an endograft

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Anatomical exclusion criteria

• Proximal or distal landing zone maximum diameter >38mm or >46 in case of planned aortic branching

• Proximal or distal landing zone length <20mm

• Circumferential calcifications or thrombus of the proximal or distal landing zone

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Anatomical exclusion criteria cont…

• Inverted funnel shaped proximal neck with >3mm increase in diameter from the proximal landing zone

• Prohibitive occlusive disease, tortuosity, or calcification of intended access vessels or in the region of the intended fixation sites

• Angulation in the aortic arch or thoraco abdominal aorta that would preclude the advancement of the introduction system

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Debranching AEVAR

• Proximal Landing ZoneZone 0

Aor-RSCA-Lt CCA-LSCA bypassBil FA –RSCA-L CCA-LSCA bypass

Zone 1R SCA-LCCA-LSCA bypass

Zone 2RSCA-LSCA bypassLCCA-LSCA bypassSimple sacrifice of LSCA

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Surgical procedure-Zone 0

• Median sternotomy• Isolation of the proximal right subclavian artery and the common

carotid artery (CCA) -- distal to the brachiocephalic bifurcation• A ‘‘Y’’ graft is tailored using an 8- to 10-mm Dacron graft and a 6-

mm Dacron graft implanted in an end to-side fashion• Systemic heparinisation, continuous EEG monitoring • Controlled hypotension, • Longitudinal arteriotomy with side clamp on ascending aorta

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Surgical procedure Zone 0 cont…

• Proximal end of the graft anastomosed to the ascending aorta

• Graft tunneled beneath the left brachiocephalic vein.

• 6-mm Dacron branch was anastomosed in end-to-end fashion to LCCA

• Stumps of the innominate A and left CCA oversewn and reinforced with Telflon felt pledgets

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The incision wound sternum was separated andcurved to right 6th intercostal space.

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Preparation of Aortic Band

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TOTAL DEBRANCHING AND AORTIC BANDING WITH GORETEX GRAFT

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Previous elephant trunk

Replaced proximal aorta

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A) Preoperative CT scan demonstratesa zone 0 aortic arch aneurysm. (B) PostoperativeCT scan demonstrates complete exclusion of theaortic arch aneurysm after total rerouting of thesupra-aortic trunks.

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Ao-rt.SCA-lt.CCA-lt.SCA bypass

Approach : Median sternotomy

Inflow : Side clamp of Ascending Aorta.

Prosthesis : 12mm Hemashield for rt. SCA 8mm Hemashield for lt.CCA & lt.SCA

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Surgical procedure-Zone 1

• 2 Anterolateral incisions

• 6 or 8mm PTFE ringed armed graft from donor carotid (end to side)to recipient carotid in an end to end fashion

• CCA ligation to prevent Type II endoleak

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(A) Preoperative CT scan of a zone 1aortic arch aneurysm. (B) Postoperative CT scan ofpartial rerouting of the aortic arch with a rightcommon carotid-to-left common carotid-to-leftsubclavian artery bypass and complete exclusionof the aortic arch aneurysm.

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Indications for LSA revascularization

• Coronary circulation supplied by the LSA through the LIMA

• Inadequate contralateral vertebral artery

• Young patients

• Left handed professionals

• High risk for spinal chord ischemia

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• Multicenter study shows LSA revascularisation is indicated in 25-30% of cases

• 498 cases of intentional LSA coverage without revascularisation in TEVAR

- Stroke rate 2.6%

- Paraplegia 1.6 % - Type 2 endoleak 1.2% - Subclavian steal syndrome 10%

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NECKLACE GRAFT

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Surgical procedure – Zone 2• LSA revascularization only in selected cases

A) Preoperative CT scan of a zone 2aortic arch aneurysm. (B) Postoperative CT scan ofa carotid-to-subclavian bypass, occlusion at theorigin of the left subclavian bypass, and completeexclusion of the aortic arch aneurysm.

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Summary

• Hybrid procedure for treating aortic arch pathology is feasible in selected patients unfit for conventional surgery.

• The outcomes are promising, but the associated mortality and

morbidity rates are not negligible.

• Promising results Evolving hybrid

Bearing on “FIT” patients for a

conventional surgery

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Thank you