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An eight-branched aortic graft for reconstruction of visceral and intercostal arteries during extent II thoraco-abdominal aortic surgery

An eight-branched aortic graft for reconstruction of visceral and intercostal arteries during... Abstract Reconstruction of the visceral and intercostal arteries is the most challenging part in the open repair of thoraco-abdominal aortic aneurysm. For efficient and expeditious reconstruction of these branching vessels, a technique of using a pre-handsewn 8-branch aortic graft (octopod technique) has been adopted. The octopod graft was manually constructed using commercially available two 4-branch aortic grafts that were spatially oriented based on the preoperative computed tomographic images and connected each other prior to surgery. This approach was adopted in 12 open repairs of extent II thoraco-abdominal aortic aneurysms from 2015 to 2017, including 8 Marfan patients. Median pump and procedural times were 173 (102–207) min and 437 (343–489) min, respectively. There was no operative mortality or spinal cord injury. The octopod technique for open thoraco-abdominal aortic aneurysm repair showed excellent early results with high procedural efficiency. Thoraco-abdominal aorta, Open repair, Branched graft, Marfan syndrome INTRODUCTION In extensive thoraco-abdominal aortic aneurysm (TAAA) repair, reconstruction of the visceral and intercostal arteries is the most challenging part. We constructed a 8-branched thoraco-abdominal aortic graft (octopod technique) to facilitate the bypassing of visceral and intercostal arteries individually. OPERATIVE TECHNIQUES The octopod graft was manually constructed using two commercially available 4-branch grafts (Coselli thoraco-abdominal graft; Vascutek Ltd, Renfrewshire, UK and Hemashield Platinum 4-branch graft; MAQUET Cardiovascular LLC, San Jose, CA, USA), which were presewed to each other during anaesthetic induction by a single layer of continuous running sutures (Fig. 1). The angle between the visceral and the intercostal branches was addressed during the construction of the octopod graft based on preoperative computed tomographic images (Fig. 1B). Figure 1 View largeDownload slide (A) The octopod TAAA aortic graft. (B) Representative computed tomographic images at the visceral and intercostal level. (C) Intraoperative findings of the octopod TAAA graft. SMA: superior mesenteric artery; TAAA: thoraco-abdominal aortic aneurysm. Figure 1 View largeDownload slide (A) The octopod TAAA aortic graft. (B) Representative computed tomographic images at the visceral and intercostal level. (C) Intraoperative findings of the octopod TAAA graft. SMA: superior mesenteric artery; TAAA: thoraco-abdominal aortic aneurysm. Cardiopulmonary bypass was established through the left femoral vessels. For those requiring hypothermic arrest for concomitant distal arch repair, we used moderate hypothermia (25–28°C). We routinely reattached at least 1 pair of segmental arteries, which were individually bypassed using the 3 sidearm branches of the graft. Distal aortic anastomosis was usually made prior to revascularization of the visceral vessels while perfusing the visceral and renal arteries. From May 2015 through February 2017, we used this approach in 12 consecutive TAAA repairs by a single surgeon (J.B.K.) at Asan Medical Center, Seoul, Korea. Individual profiles of the subject patients are detailed in Table 1. Median cardiopulmonary bypass and total procedural times were 173 (range 102–207) min and 437 (range 342–489) min, respectively. There was no perioperative mortality or neurological dysfunction. Immediate postoperative computed tomography angiography was performed in all patients, which demonstrated the patency of all bypassed grafts in the segmental, visceral and renal arteries. Table 1: Baseline and operative profiles of the patients and perioperative outcomes Patient Age (years) Gender Marfan No. of prior aortic surgery Prior aortic surgery Need for HCA Level of ICA bypassed 1a 26 M Y 1 Root + total arch Y T12, L1 2a 36 F Y 1 Root + hemiarch Y L1 3 48 M N 0 N/A N T11 4a 42 M Y 1 Root + total arch Y T11, L2 5a 37 M Y 1 Root + total arch N T10, L2 6a 24 M Y 1 Root + total arch Y T11, L1, 2 7a 36 F Y 1 Root + total arch Y T9, T11 8 53 M N 0 NA Y T10, T12 9 40 M N 2 Hemiarch/TAAA N T11 10 36 F N 1 Hemiarch N T10, 11 11a 40 M Y 3 Root/total arch/TAAA Y T10, 11 12a 50 M Y 1 Root + hemiarch N T10, 11, L1 Patient Age (years) Gender Marfan No. of prior aortic surgery Prior aortic surgery Need for HCA Level of ICA bypassed 1a 26 M Y 1 Root + total arch Y T12, L1 2a 36 F Y 1 Root + hemiarch Y L1 3 48 M N 0 N/A N T11 4a 42 M Y 1 Root + total arch Y T11, L2 5a 37 M Y 1 Root + total arch N T10, L2 6a 24 M Y 1 Root + total arch Y T11, L1, 2 7a 36 F Y 1 Root + total arch Y T9, T11 8 53 M N 0 NA Y T10, T12 9 40 M N 2 Hemiarch/TAAA N T11 10 36 F N 1 Hemiarch N T10, 11 11a 40 M Y 3 Root/total arch/TAAA Y T10, 11 12a 50 M Y 1 Root + hemiarch N T10, 11, L1 a These 8 patients had the completion of entire aortic replacement using the current technique. AC: aortic clamping; CD: chronic aortic dissection; CKD: chronic kidney disease; DA: degenerative aneurysm; F: female; HCA: hypothermic circulatory arrest; ICA: intercostal artery; M: male; N: no; TAAA: thoraco-abdominal aortic aneurysm; Y: yes. Table 1: Baseline and operative profiles of the patients and perioperative outcomes Patient Age (years) Gender Marfan No. of prior aortic surgery Prior aortic surgery Need for HCA Level of ICA bypassed 1a 26 M Y 1 Root + total arch Y T12, L1 2a 36 F Y 1 Root + hemiarch Y L1 3 48 M N 0 N/A N T11 4a 42 M Y 1 Root + total arch Y T11, L2 5a 37 M Y 1 Root + total arch N T10, L2 6a 24 M Y 1 Root + total arch Y T11, L1, 2 7a 36 F Y 1 Root + total arch Y T9, T11 8 53 M N 0 NA Y T10, T12 9 40 M N 2 Hemiarch/TAAA N T11 10 36 F N 1 Hemiarch N T10, 11 11a 40 M Y 3 Root/total arch/TAAA Y T10, 11 12a 50 M Y 1 Root + hemiarch N T10, 11, L1 Patient Age (years) Gender Marfan No. of prior aortic surgery Prior aortic surgery Need for HCA Level of ICA bypassed 1a 26 M Y 1 Root + total arch Y T12, L1 2a 36 F Y 1 Root + hemiarch Y L1 3 48 M N 0 N/A N T11 4a 42 M Y 1 Root + total arch Y T11, L2 5a 37 M Y 1 Root + total arch N T10, L2 6a 24 M Y 1 Root + total arch Y T11, L1, 2 7a 36 F Y 1 Root + total arch Y T9, T11 8 53 M N 0 NA Y T10, T12 9 40 M N 2 Hemiarch/TAAA N T11 10 36 F N 1 Hemiarch N T10, 11 11a 40 M Y 3 Root/total arch/TAAA Y T10, 11 12a 50 M Y 1 Root + hemiarch N T10, 11, L1 a These 8 patients had the completion of entire aortic replacement using the current technique. AC: aortic clamping; CD: chronic aortic dissection; CKD: chronic kidney disease; DA: degenerative aneurysm; F: female; HCA: hypothermic circulatory arrest; ICA: intercostal artery; M: male; N: no; TAAA: thoraco-abdominal aortic aneurysm; Y: yes. DISCUSSION In the open TAAA repair, patch aneurysm formation following the conventional Crawford’s inclusion/island technique has been reported to be as high as 7.5% [1–3]. Separate revascularization technique using multibranched graft has been suggested to overcome the limitation of the conventional methods, and there has been general agreement on the use of separate grafting for younger individuals or those with connective tissue disorders [4, 5]. Even with the use of branched TAAA grafts, it has still been standard practice to revascularize segmental arteries by conventional inclusion/island methods. Furthermore, when the segmental arteries are to be separately bypassed, multiple grafts have to be individually sewed to the main graft, which may be troublesome. To overcome these limitations, we preconstructed the octopod aortic graft to improve procedural efficiency. The results of our preliminary experiences indicate that the octopod technique may be a reasonable approach to improve procedural efficiency and safety in challenging open TAAA repairs. Funding This study was supported by the Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea [2016-033]. Conflict of interest: none declared. REFERENCES 1 Crawford ES. Thoraco-abdominal and abdominal aortic aneurysms involving renal, superior mesenteric, celiac arteries . Ann Surg 1974 ; 179 : 763 – 72 . Google Scholar CrossRef Search ADS PubMed 2 Dardik A , Perler BA , Roseborough GS , Williams GM. Aneurysmal expansion of the visceral patch after thoracoabdominal aortic replacement: an argument for limiting patch size? J Vasc Surg 2001 ; 34 : 405 – 9 ; discussion 10. Google Scholar CrossRef Search ADS PubMed 3 Kulik A , Allen BT , Kouchoukos NT. Incidence and management of intercostal patch aneurysms after repair of thoracoabdominal aortic aneurysms . J Thorac Cardiovasc Surg 2009 ; 138 : 352 – 8 . Google Scholar CrossRef Search ADS PubMed 4 de la Cruz KI , LeMaire SA , Weldon SA , Coselli JS. Thoracoabdominal aortic aneurysm repair with a branched graft . Ann Cardiothorac Surg 2012 ; 1 : 381 – 93 . Google Scholar PubMed 5 De Rango P , Estrera AL , Miller C 3rd , Lee TY , Keyhani K , Abdullah S et al. Operative outcomes using a side-branched thoracoabdominal aortic graft (STAG) for thoraco-abdominal aortic repair . Eur J Vasc Endovasc Surg 2011 ; 41 : 41 – 7 . Google Scholar CrossRef Search ADS PubMed © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

An eight-branched aortic graft for reconstruction of visceral and intercostal arteries during extent II thoraco-abdominal aortic surgery

Park, Sung Jun; Kim, Joon Bum
European Journal of Cardio-Thoracic Surgery , Volume Advance Article (6) – Nov 20, 2017
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Oxford University Press
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© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1010-7940
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Abstract

Abstract Reconstruction of the visceral and intercostal arteries is the most challenging part in the open repair of thoraco-abdominal aortic aneurysm. For efficient and expeditious reconstruction of these branching vessels, a technique of using a pre-handsewn 8-branch aortic graft (octopod technique) has been adopted. The octopod graft was manually constructed using commercially available two 4-branch aortic grafts that were spatially oriented based on the preoperative computed tomographic images and connected each other prior to surgery. This approach was adopted in 12 open repairs of extent II thoraco-abdominal aortic aneurysms from 2015 to 2017, including 8 Marfan patients. Median pump and procedural times were 173 (102–207) min and 437 (343–489) min, respectively. There was no operative mortality or spinal cord injury. The octopod technique for open thoraco-abdominal aortic aneurysm repair showed excellent early results with high procedural efficiency. Thoraco-abdominal aorta, Open repair, Branched graft, Marfan syndrome INTRODUCTION In extensive thoraco-abdominal aortic aneurysm (TAAA) repair, reconstruction of the visceral and intercostal arteries is the most challenging part. We constructed a 8-branched thoraco-abdominal aortic graft (octopod technique) to facilitate the bypassing of visceral and intercostal arteries individually. OPERATIVE TECHNIQUES The octopod graft was manually constructed using two commercially available 4-branch grafts (Coselli thoraco-abdominal graft; Vascutek Ltd, Renfrewshire, UK and Hemashield Platinum 4-branch graft; MAQUET Cardiovascular LLC, San Jose, CA, USA), which were presewed to each other during anaesthetic induction by a single layer of continuous running sutures (Fig. 1). The angle between the visceral and the intercostal branches was addressed during the construction of the octopod graft based on preoperative computed tomographic images (Fig. 1B). Figure 1 View largeDownload slide (A) The octopod TAAA aortic graft. (B) Representative computed tomographic images at the visceral and intercostal level. (C) Intraoperative findings of the octopod TAAA graft. SMA: superior mesenteric artery; TAAA: thoraco-abdominal aortic aneurysm. Figure 1 View largeDownload slide (A) The octopod TAAA aortic graft. (B) Representative computed tomographic images at the visceral and intercostal level. (C) Intraoperative findings of the octopod TAAA graft. SMA: superior mesenteric artery; TAAA: thoraco-abdominal aortic aneurysm. Cardiopulmonary bypass was established through the left femoral vessels. For those requiring hypothermic arrest for concomitant distal arch repair, we used moderate hypothermia (25–28°C). We routinely reattached at least 1 pair of segmental arteries, which were individually bypassed using the 3 sidearm branches of the graft. Distal aortic anastomosis was usually made prior to revascularization of the visceral vessels while perfusing the visceral and renal arteries. From May 2015 through February 2017, we used this approach in 12 consecutive TAAA repairs by a single surgeon (J.B.K.) at Asan Medical Center, Seoul, Korea. Individual profiles of the subject patients are detailed in Table 1. Median cardiopulmonary bypass and total procedural times were 173 (range 102–207) min and 437 (range 342–489) min, respectively. There was no perioperative mortality or neurological dysfunction. Immediate postoperative computed tomography angiography was performed in all patients, which demonstrated the patency of all bypassed grafts in the segmental, visceral and renal arteries. Table 1: Baseline and operative profiles of the patients and perioperative outcomes Patient Age (years) Gender Marfan No. of prior aortic surgery Prior aortic surgery Need for HCA Level of ICA bypassed 1a 26 M Y 1 Root + total arch Y T12, L1 2a 36 F Y 1 Root + hemiarch Y L1 3 48 M N 0 N/A N T11 4a 42 M Y 1 Root + total arch Y T11, L2 5a 37 M Y 1 Root + total arch N T10, L2 6a 24 M Y 1 Root + total arch Y T11, L1, 2 7a 36 F Y 1 Root + total arch Y T9, T11 8 53 M N 0 NA Y T10, T12 9 40 M N 2 Hemiarch/TAAA N T11 10 36 F N 1 Hemiarch N T10, 11 11a 40 M Y 3 Root/total arch/TAAA Y T10, 11 12a 50 M Y 1 Root + hemiarch N T10, 11, L1 Patient Age (years) Gender Marfan No. of prior aortic surgery Prior aortic surgery Need for HCA Level of ICA bypassed 1a 26 M Y 1 Root + total arch Y T12, L1 2a 36 F Y 1 Root + hemiarch Y L1 3 48 M N 0 N/A N T11 4a 42 M Y 1 Root + total arch Y T11, L2 5a 37 M Y 1 Root + total arch N T10, L2 6a 24 M Y 1 Root + total arch Y T11, L1, 2 7a 36 F Y 1 Root + total arch Y T9, T11 8 53 M N 0 NA Y T10, T12 9 40 M N 2 Hemiarch/TAAA N T11 10 36 F N 1 Hemiarch N T10, 11 11a 40 M Y 3 Root/total arch/TAAA Y T10, 11 12a 50 M Y 1 Root + hemiarch N T10, 11, L1 a These 8 patients had the completion of entire aortic replacement using the current technique. AC: aortic clamping; CD: chronic aortic dissection; CKD: chronic kidney disease; DA: degenerative aneurysm; F: female; HCA: hypothermic circulatory arrest; ICA: intercostal artery; M: male; N: no; TAAA: thoraco-abdominal aortic aneurysm; Y: yes. Table 1: Baseline and operative profiles of the patients and perioperative outcomes Patient Age (years) Gender Marfan No. of prior aortic surgery Prior aortic surgery Need for HCA Level of ICA bypassed 1a 26 M Y 1 Root + total arch Y T12, L1 2a 36 F Y 1 Root + hemiarch Y L1 3 48 M N 0 N/A N T11 4a 42 M Y 1 Root + total arch Y T11, L2 5a 37 M Y 1 Root + total arch N T10, L2 6a 24 M Y 1 Root + total arch Y T11, L1, 2 7a 36 F Y 1 Root + total arch Y T9, T11 8 53 M N 0 NA Y T10, T12 9 40 M N 2 Hemiarch/TAAA N T11 10 36 F N 1 Hemiarch N T10, 11 11a 40 M Y 3 Root/total arch/TAAA Y T10, 11 12a 50 M Y 1 Root + hemiarch N T10, 11, L1 Patient Age (years) Gender Marfan No. of prior aortic surgery Prior aortic surgery Need for HCA Level of ICA bypassed 1a 26 M Y 1 Root + total arch Y T12, L1 2a 36 F Y 1 Root + hemiarch Y L1 3 48 M N 0 N/A N T11 4a 42 M Y 1 Root + total arch Y T11, L2 5a 37 M Y 1 Root + total arch N T10, L2 6a 24 M Y 1 Root + total arch Y T11, L1, 2 7a 36 F Y 1 Root + total arch Y T9, T11 8 53 M N 0 NA Y T10, T12 9 40 M N 2 Hemiarch/TAAA N T11 10 36 F N 1 Hemiarch N T10, 11 11a 40 M Y 3 Root/total arch/TAAA Y T10, 11 12a 50 M Y 1 Root + hemiarch N T10, 11, L1 a These 8 patients had the completion of entire aortic replacement using the current technique. AC: aortic clamping; CD: chronic aortic dissection; CKD: chronic kidney disease; DA: degenerative aneurysm; F: female; HCA: hypothermic circulatory arrest; ICA: intercostal artery; M: male; N: no; TAAA: thoraco-abdominal aortic aneurysm; Y: yes. DISCUSSION In the open TAAA repair, patch aneurysm formation following the conventional Crawford’s inclusion/island technique has been reported to be as high as 7.5% [1–3]. Separate revascularization technique using multibranched graft has been suggested to overcome the limitation of the conventional methods, and there has been general agreement on the use of separate grafting for younger individuals or those with connective tissue disorders [4, 5]. Even with the use of branched TAAA grafts, it has still been standard practice to revascularize segmental arteries by conventional inclusion/island methods. Furthermore, when the segmental arteries are to be separately bypassed, multiple grafts have to be individually sewed to the main graft, which may be troublesome. To overcome these limitations, we preconstructed the octopod aortic graft to improve procedural efficiency. The results of our preliminary experiences indicate that the octopod technique may be a reasonable approach to improve procedural efficiency and safety in challenging open TAAA repairs. Funding This study was supported by the Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea [2016-033]. Conflict of interest: none declared. REFERENCES 1 Crawford ES. Thoraco-abdominal and abdominal aortic aneurysms involving renal, superior mesenteric, celiac arteries . Ann Surg 1974 ; 179 : 763 – 72 . Google Scholar CrossRef Search ADS PubMed 2 Dardik A , Perler BA , Roseborough GS , Williams GM. Aneurysmal expansion of the visceral patch after thoracoabdominal aortic replacement: an argument for limiting patch size? J Vasc Surg 2001 ; 34 : 405 – 9 ; discussion 10. Google Scholar CrossRef Search ADS PubMed 3 Kulik A , Allen BT , Kouchoukos NT. Incidence and management of intercostal patch aneurysms after repair of thoracoabdominal aortic aneurysms . J Thorac Cardiovasc Surg 2009 ; 138 : 352 – 8 . Google Scholar CrossRef Search ADS PubMed 4 de la Cruz KI , LeMaire SA , Weldon SA , Coselli JS. Thoracoabdominal aortic aneurysm repair with a branched graft . Ann Cardiothorac Surg 2012 ; 1 : 381 – 93 . Google Scholar PubMed 5 De Rango P , Estrera AL , Miller C 3rd , Lee TY , Keyhani K , Abdullah S et al. Operative outcomes using a side-branched thoracoabdominal aortic graft (STAG) for thoraco-abdominal aortic repair . Eur J Vasc Endovasc Surg 2011 ; 41 : 41 – 7 . Google Scholar CrossRef Search ADS PubMed © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

European Journal of Cardio-Thoracic Surgery – Oxford University Press

Published: Nov 20, 2017

References

  • Thoraco-abdominal and abdominal aortic aneurysms involving renal, superior mesenteric, celiac arteries
    Crawford
  • Aneurysmal expansion of the visceral patch after thoracoabdominal aortic replacement: an argument for limiting patch size?
    Dardik
  • Incidence and management of intercostal patch aneurysms after repair of thoracoabdominal aortic aneurysms
    Kulik
  • Thoracoabdominal aortic aneurysm repair with a branched graft
    de la Cruz
  • Operative outcomes using a side-branched thoracoabdominal aortic graft (STAG) for thoraco-abdominal aortic repair
    De Rango