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      Anomalies and variant anatomy of the aorta and the supra-aortic vessels: additional challenges met by hybrid procedures

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          Abstract

          Introduction

          Endovascular or hybrid approach to the aortic arch aneurysms is nowadays an appealing solution for selected patients. Aim of this retrospective study is to evaluate the technical and clinical success recorded in complex anatomical settings of endografting.

          Methods

          Between December 2004 and December 2008, 73 patients were treated with a stent-graft for thoracic aorta aneurysms at our Vascular and Endovascular Surgery center, or in other Italian Centers by our Vascular Surgeon as Proctor. The aortic arch was involved in 31 cases. Four cases of bovine arch, three aberrant right subclavian artery and one case of isolated origin of all the supra-aortic trunks (6 vessels) were recorded. Technical success, procedural planning time and procedural time, stroke and paraplegia incidences were analyzed in terms of difference between “normal” or “complex” arches.

          Results

          Technical success was achieved in all cases. Complex anatomy of the arch and the supra-aortic trunks increased the technical difficulty of endovascular exclusion of the aneurysm and required more often complex debranching of the supra-aortic vessel necessary to obtain an adequate landing zone and to preserve the brain and spinal cord perfusion. We observed one stroke in complex arches procedures and two strokes (one of them fatal) in normal arch procedures. No cases of paraplegia were observed.

          Conclusions

          In our experience complex anatomy of the arch did not represent a predictive factor in term of peri-procedural major neurological adverse events.

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          Most cited references 31

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          Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms.

          The usual treatment for thoracic aortic aneurysms is surgical replacement with a prosthetic graft, but the associated morbidity and mortality are considerable. We studied the use of transluminally placed endovascular stent-graft devices as an alternative to surgical repair. We evaluated the feasibility, safety, and effectiveness of transluminally placed stent-graft to treat descending thoracic aortic aneurysms in 13 patients over a 24-month period. Atherosclerotic, anastomotic, and post-traumatic true or false aneurysms and aortic dissections were treated. The mean diameter of the aneurysms was 6.1 cm (range, 5 to 8). The endovascular stent-grafts were custom-designed for each patient and were constructed of self-expanding stainless-steel stents covered with woven Dacron grafts. Endovascular placement of the stent-graft prosthesis was successful in all patients. There was complete thrombosis of the thoracic aortic aneurysm surrounding the stent-graft in 12 patients, and partial thrombosis in 1. Two patients initially had small, residual patent proximal tracts into the aneurysm sac, but both tracts thrombosed within two months after the procedure. In four patients, two prostheses were required to bridge the aneurysm adequately. There have been no deaths or instances of paraplegia, stroke, distal embolization, or infection during an average follow-up of 11.6 months. One patient with an extensive chronic aortic dissection required open surgical graft replacement four months later because of progressive dilatation of the arch. These preliminary results demonstrate that endovascular stent-graft repair is safe in highly selected patients with descending thoracic aortic aneurysms. This new method of treatment will, however, require careful long-term evaluation.
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            Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement.

            The treatment of thoracic aortic dissection is guided by prognostic and anatomical information. Proximal dissection requires surgery, but the appropriate treatment of distal thoracic aortic dissection has not been determined, because surgery has failed to improve the prognosis. We prospectively evaluated the safety and efficacy of elective transluminal endovascular stent-graft insertion in 12 consecutive patients with descending (type B) aortic dissection and compared the results with surgery in 12 matched controls. In all 24 patients, aortic dissection was diagnosed by magnetic resonance angiography. In each group, the dissection involved the aortic arch in 3 patients and the descending thoracic aorta in all 12 patients. With the patient under general anesthesia, either surgical resection was undertaken or a custom-designed endovascular stent-graft was placed by unilateral arteriotomy. Stent-graft placement resulted in no morbidity or mortality, whereas surgery for type B dissection was associated with four deaths (33 percent, P=0.09) and five serious adverse events (42 percent, P=0.04) within 12 months. Transluminal placement of the stent-graft prosthesis was successful in all patients, with no leakage; full expansion of the stents was ensured by balloon inflation at 2 to 3 atm. Sealing of the entry tear was monitored during the procedure by transesophageal ultrasonography and angiography, and thrombosis of the false lumen was confirmed in all 12 patients after a mean of three months by magnetic resonance imaging. There were no deaths or instances of paraplegia, stroke, embolization, side-branch occlusion, or infection in the stent-graft group; nine patients had postimplantation syndrome, with transient elevation of C-reactive protein levels and body temperature plus mild leukocytosis. All the patients who received stent-grafts recovered, as did seven patients who underwent surgery for type B dissection (58 percent) (P=0.04). These preliminary observations suggest that elective, nonsurgical insertion of an endovascular stent-graft is safe and efficacious in selected patients who have thoracic aortic dissection and for whom surgery is indicated. Endoluminal repair may be useful for interventional reconstruction of thoracic aortic dissection.
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              Anomalies of the derivatives of the aortic arch system.

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                Author and article information

                Affiliations
                Department of Surgery, Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy
                Author notes
                Francesco Setacci Department of Surgery Vascular and Endovascular Surgery Unit University of Siena, Siena, Italy; E-mail: setacci@ 123456unisi.it
                Journal
                HSR Proc Intensive Care Cardiovasc Anesth
                HSR Proc Intensive Care Cardiovasc Anesth
                2037-0504
                hsrp
                HSR Proceedings in Intensive Care & Cardiovascular Anesthesia
                EDIMES Edizioni Internazionali Srl
                2037-0504
                2037-0512
                2009
                : 1
                : 1
                : 37-44
                23438787 3484532 200901137
                Copyright © 2009, HSR Proceedings in Intensive Care and Cardiovascular Anesthesia

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License 3.0, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/3.0/ and http://creativecommons.org/licenses/by-nc/3.0/legalcode.

                Categories
                Research-Article

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