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Antegrade transapical branch deployment for endovascular aortic-arch repair by in situ fenestration

Antegrade transapical branch deployment for endovascular aortic-arch repair by in situ fenestration Abstract A 76-year-old man presented with an aortic arch aneurysm and was considered a candidate for endovascular aortic arch repair by in situ fenestration. Alternative access routes were explored because of atherosclerotic disease of the descending aorta and bilateral carotid arteries. Transapical deployment of both an aortic and a branched stent grafts was successfully conducted without cerebral complications. The transapical access might have the potential to reduce the risks of complications related to large bore-sheath insertion to the carotid arteries. Transapical access, Endovascular aortic-arch repair, In situ fenestration INTRODUCTION The carotid artery is the common access route for mating-graft deployment in endovascular branched aortic-arch repair. It might involve large bore-sheath insertion to these vessels, with risk of vessel injury or embolic stroke. Here, we describe a patient with an aortic arch aneurysm, for whom the left ventricular apex was the most suitable access for aortic and branch stent graft deployment during thoracic endovascular repair (TEVAR) with in situ fenestration. CASE REPORT A 76-year-old male was referred for treatment of an aortic arch aneurysm. Multiple comorbidities and frailty precluded open repair. Abundant atheromatous plaques in the descending aorta (Fig. 1) and atherosclerotic wall thickening of the carotid artery were recognized. A multidisciplinary team decided on a transapical approach for TEVAR. We obtained permission from the institutional review board for the procedure (303199). Informed consent was obtained from the patient. Figure 1: Open in new tabDownload slide Pre- and postoperative computed tomographic (CT) images. (A) Three-dimensional reconstruction of the CT angiogram revealing the saccular aneurysm of the aortic arch. (B) Multiplanar reconstruction revealing abundant and irregular atheromatous plaques on the aorta. (C) Postoperative CT angiogram revealed patent branch grafts. Figure 1: Open in new tabDownload slide Pre- and postoperative computed tomographic (CT) images. (A) Three-dimensional reconstruction of the CT angiogram revealing the saccular aneurysm of the aortic arch. (B) Multiplanar reconstruction revealing abundant and irregular atheromatous plaques on the aorta. (C) Postoperative CT angiogram revealed patent branch grafts. First, a left carotid to left axillary bypass was constructed as a debranching. Partial cardiopulmonary bypass was established with an arterial inflow to this bypass graft and the right axillary artery to establish an isolated circulation to the brain throughout the procedure [1]. A 22-Fr Gore DrySeal sheath (WL Gore & Associates, Flagstaff, AZ, USA) was introduced from the left ventricular apex. A conformable TAG stent graft (WL Gore & Associates) was deployed from zone 0 to zone 3. Six-French sheaths were introduced into both the open common carotid arteries to puncture the conformable TAG with an 18-gauge, 30-cm needle (PTC needle, Hakko Co., Ltd, Tokyo, Japan). After externalizing a 0.035-inch stiff wire from the neck to the left-ventricular apex, the puncture hole was dilated with a balloon, followed by antegrade advancement of the delivery sheath. The through-&-through wire helped overcome the challenge of resistance while advancing the balloon and delivery sheaths through the smaller fenestration [2]. For left carotid artery reconstruction, an 8-mm GORE® VIABAHN® VBX Balloon Expandable Endoprosthesis was used, whereas for the brachiocephalic artery, a 12-Fr 45-cm sheath was introduced to deliver a 9.5-cm Gore Excluder leg. A kissing balloon was used to touch up both grafts (Fig. 2B). Coil embolization was performed at the left subclavian arterial origin. Aortography did not show any endoleak. Figure 2: Open in new tabDownload slide  A conceptual drawing (A) and an intraoperative fluoroscopic image (B) of the procedure. (A) Drawing showing the concept of transapical deployment of the supra-aortic branch along the through-and-through wire. (B) Kissing balloons applied to both supra-aortic branch grafts. Figure 2: Open in new tabDownload slide  A conceptual drawing (A) and an intraoperative fluoroscopic image (B) of the procedure. (A) Drawing showing the concept of transapical deployment of the supra-aortic branch along the through-and-through wire. (B) Kissing balloons applied to both supra-aortic branch grafts. The patient was extubated on the next day without neurological deficits. However, the postoperative course was complicated with respiratory failure and acute renal failure. He was transferred to a rehabilitation facility on postoperative day 60. Computed tomography angiogram on postoperative day 28 showed patent supra-aortic branch grafts, with minimal endoleak of an unknown origin. DISCUSSION Most recently developed branched endografts for aortic arch repair are not commercially available in Japan. Therefore, we routinely adopt in situ fenestration. Recently, a multicentre analysis demonstrated that this technique is a valuable option for selected patients [3]. Mating-branch deployment commonly involves common carotid artery cannulation with relatively large bore sheaths. This carries a risk of carotid artery dissection or cerebral ischaemia during the procedure. Furthermore, these arteries could be anatomically unsuitable as access routes. As an alternative, an antegrade approach for side-branch deployment was proven feasible first in an animal model [4], followed by a clinical success [5]. In the present case, transapical deployment of the branch device was safely performed, with only 6-Fr low-profile sheaths introduced into the bilateral common carotid arteries to puncture the aortic stent graft. CONCLUSION Transapical deployment of both aortic and branch stent grafts was safely performed during TEVAR with in situ fenestration, with the potential benefit of risk reduction. Conflict of interest: none declared. REFERENCES 1 Murakami T , Nishimura S , Hosono M , Nakamura Y , Sohgawa E , Sakai Y et al. Transapical endovascular repair of thoracic aortic pathology . Ann Vasc Surg 2017 ; 43 : 56 – 64 . 2 Murakami T , Morisaki A , Nishimura S , Takahashi Y , Sakon Y , Nakano M et al. Externalized transapical guidewire technique for complex aortic disease: a single-centre experience . Eur J Cardiothorac Surg 2019 ; 55 : 639 – 45 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Kopp R , Katada Y , Kondo S , Sonesson B , Hongo N , Tse L et al. Multicenter analysis of endovascular aortic arch in situ stent graft fenestrations for aortic arch pathologies . Ann Vasc Surg 2019 ; doi: 10.1016/j.avsg.2019.02.005. OpenURL Placeholder Text WorldCat 4 Wipper S , Lohrenz C , Kersten JF , Akkra MM , Tsilimparis N , Detter C et al. Complete antegrade transapical deployment of a branched aortic arch endograft: a porcine feasibility study . J Endovasc Ther 2016 ; 23 : 493 – 500 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Law Y , Kölbel T , Schirmer J , Aleed S , Mogensen J , Debus ES et al. Transapical access for antegrade catheterization of the inner branches of an arch stent-graft deployed distal to an ascending arch stent-graft . J Endovasc Ther 2018 ; 25 : 542 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2019. 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/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

Antegrade transapical branch deployment for endovascular aortic-arch repair by in situ fenestration

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Publisher
Oxford University Press
Copyright
© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ISSN
1010-7940
eISSN
1873-734X
DOI
10.1093/ejcts/ezz223
Publisher site
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Abstract

Abstract A 76-year-old man presented with an aortic arch aneurysm and was considered a candidate for endovascular aortic arch repair by in situ fenestration. Alternative access routes were explored because of atherosclerotic disease of the descending aorta and bilateral carotid arteries. Transapical deployment of both an aortic and a branched stent grafts was successfully conducted without cerebral complications. The transapical access might have the potential to reduce the risks of complications related to large bore-sheath insertion to the carotid arteries. Transapical access, Endovascular aortic-arch repair, In situ fenestration INTRODUCTION The carotid artery is the common access route for mating-graft deployment in endovascular branched aortic-arch repair. It might involve large bore-sheath insertion to these vessels, with risk of vessel injury or embolic stroke. Here, we describe a patient with an aortic arch aneurysm, for whom the left ventricular apex was the most suitable access for aortic and branch stent graft deployment during thoracic endovascular repair (TEVAR) with in situ fenestration. CASE REPORT A 76-year-old male was referred for treatment of an aortic arch aneurysm. Multiple comorbidities and frailty precluded open repair. Abundant atheromatous plaques in the descending aorta (Fig. 1) and atherosclerotic wall thickening of the carotid artery were recognized. A multidisciplinary team decided on a transapical approach for TEVAR. We obtained permission from the institutional review board for the procedure (303199). Informed consent was obtained from the patient. Figure 1: Open in new tabDownload slide Pre- and postoperative computed tomographic (CT) images. (A) Three-dimensional reconstruction of the CT angiogram revealing the saccular aneurysm of the aortic arch. (B) Multiplanar reconstruction revealing abundant and irregular atheromatous plaques on the aorta. (C) Postoperative CT angiogram revealed patent branch grafts. Figure 1: Open in new tabDownload slide Pre- and postoperative computed tomographic (CT) images. (A) Three-dimensional reconstruction of the CT angiogram revealing the saccular aneurysm of the aortic arch. (B) Multiplanar reconstruction revealing abundant and irregular atheromatous plaques on the aorta. (C) Postoperative CT angiogram revealed patent branch grafts. First, a left carotid to left axillary bypass was constructed as a debranching. Partial cardiopulmonary bypass was established with an arterial inflow to this bypass graft and the right axillary artery to establish an isolated circulation to the brain throughout the procedure [1]. A 22-Fr Gore DrySeal sheath (WL Gore & Associates, Flagstaff, AZ, USA) was introduced from the left ventricular apex. A conformable TAG stent graft (WL Gore & Associates) was deployed from zone 0 to zone 3. Six-French sheaths were introduced into both the open common carotid arteries to puncture the conformable TAG with an 18-gauge, 30-cm needle (PTC needle, Hakko Co., Ltd, Tokyo, Japan). After externalizing a 0.035-inch stiff wire from the neck to the left-ventricular apex, the puncture hole was dilated with a balloon, followed by antegrade advancement of the delivery sheath. The through-&-through wire helped overcome the challenge of resistance while advancing the balloon and delivery sheaths through the smaller fenestration [2]. For left carotid artery reconstruction, an 8-mm GORE® VIABAHN® VBX Balloon Expandable Endoprosthesis was used, whereas for the brachiocephalic artery, a 12-Fr 45-cm sheath was introduced to deliver a 9.5-cm Gore Excluder leg. A kissing balloon was used to touch up both grafts (Fig. 2B). Coil embolization was performed at the left subclavian arterial origin. Aortography did not show any endoleak. Figure 2: Open in new tabDownload slide  A conceptual drawing (A) and an intraoperative fluoroscopic image (B) of the procedure. (A) Drawing showing the concept of transapical deployment of the supra-aortic branch along the through-and-through wire. (B) Kissing balloons applied to both supra-aortic branch grafts. Figure 2: Open in new tabDownload slide  A conceptual drawing (A) and an intraoperative fluoroscopic image (B) of the procedure. (A) Drawing showing the concept of transapical deployment of the supra-aortic branch along the through-and-through wire. (B) Kissing balloons applied to both supra-aortic branch grafts. The patient was extubated on the next day without neurological deficits. However, the postoperative course was complicated with respiratory failure and acute renal failure. He was transferred to a rehabilitation facility on postoperative day 60. Computed tomography angiogram on postoperative day 28 showed patent supra-aortic branch grafts, with minimal endoleak of an unknown origin. DISCUSSION Most recently developed branched endografts for aortic arch repair are not commercially available in Japan. Therefore, we routinely adopt in situ fenestration. Recently, a multicentre analysis demonstrated that this technique is a valuable option for selected patients [3]. Mating-branch deployment commonly involves common carotid artery cannulation with relatively large bore sheaths. This carries a risk of carotid artery dissection or cerebral ischaemia during the procedure. Furthermore, these arteries could be anatomically unsuitable as access routes. As an alternative, an antegrade approach for side-branch deployment was proven feasible first in an animal model [4], followed by a clinical success [5]. In the present case, transapical deployment of the branch device was safely performed, with only 6-Fr low-profile sheaths introduced into the bilateral common carotid arteries to puncture the aortic stent graft. CONCLUSION Transapical deployment of both aortic and branch stent grafts was safely performed during TEVAR with in situ fenestration, with the potential benefit of risk reduction. Conflict of interest: none declared. REFERENCES 1 Murakami T , Nishimura S , Hosono M , Nakamura Y , Sohgawa E , Sakai Y et al. Transapical endovascular repair of thoracic aortic pathology . Ann Vasc Surg 2017 ; 43 : 56 – 64 . 2 Murakami T , Morisaki A , Nishimura S , Takahashi Y , Sakon Y , Nakano M et al. Externalized transapical guidewire technique for complex aortic disease: a single-centre experience . Eur J Cardiothorac Surg 2019 ; 55 : 639 – 45 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Kopp R , Katada Y , Kondo S , Sonesson B , Hongo N , Tse L et al. Multicenter analysis of endovascular aortic arch in situ stent graft fenestrations for aortic arch pathologies . Ann Vasc Surg 2019 ; doi: 10.1016/j.avsg.2019.02.005. OpenURL Placeholder Text WorldCat 4 Wipper S , Lohrenz C , Kersten JF , Akkra MM , Tsilimparis N , Detter C et al. Complete antegrade transapical deployment of a branched aortic arch endograft: a porcine feasibility study . J Endovasc Ther 2016 ; 23 : 493 – 500 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Law Y , Kölbel T , Schirmer J , Aleed S , Mogensen J , Debus ES et al. Transapical access for antegrade catheterization of the inner branches of an arch stent-graft deployed distal to an ascending arch stent-graft . J Endovasc Ther 2018 ; 25 : 542 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2019. 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/open_access/funder_policies/chorus/standard_publication_model)

Journal

European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Feb 1, 2020

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