Surgical Techniques of Debranching in Hybrid Arch Procedures Dr. Manoj . P Lead Consultant, Aster Cardiac Sciences Aster Med city, Kochi.
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