Hybrid Treatment for Thoracic Aortic Aneurysm Combined with Aberrant Right Subclavian Artery
An 84-year-old man presented with chest pain on left side. He was a smoker of 60 years' standing and had been previously diagnosed with hypercholesterolemia. However, he had no past history of hypertension or diabetes. A chest X-ray showed markedly dilated aortic notch. Computed tomography (CT) aortography revealed an ARSA originating from the distal aortic arch, distal to the left subclavian artery and crossing the mediastinum between esophagus and trachea, and a thoracic aortic aneurysm with a diameter of 67 mm and a thrombus extending from the left subclavian artery origin to the proximal descending aorta involving the right subclavian artery origin (). The ascending aorta was also dilated with a maximal diameter of 40 mm and showed partial calcification on the anterior aorta wall. Electrocardiogram was nonspecific. Echocardiography showed normal sized cardiac chambers with left ventricle ejection fraction of 74%. Thoracic aortography confirmed the CT findings. Coronary angiography demonstrated 50% narrowing of the proximal left anterior descending artery. CT brain also revealed that the circle of Willis and both vertebral arteries were patent. Results of laboratory tests showed elevated total serum cholesterol (237 mg/dL) and low density lipoprotein cholesterol levels (164 mg/dL).\nWe decided to perform a staged hybrid procedure combining surgical replacement of the ascending aorta and bilateral carotid-tosubclavian artery bypass with implantation of a stent graft in aortic arch and descending aorta. In the first stage of the procedure, the ascending aorta was replaced by a graft. Under general anesthesia, median sternotomy was performed. Cardiopulmonary bypass was performed after cannulation of the right axillary artery and the right atrium. The ascending aorta was clamped and the heart was arrested with cold antegrade cardioplegia infusion. After selective antegrade cerebral perfusion was started, the ascending aorta was replaced using 4-branched hemashield graft (28, 10, 8, 8, 10 mm, Boston Scientific, Wayne, NJ, USA). Two 10 mm graft branches were ligated. The other two 8 mm graft branches were anastomosed with each of the common carotid arteries. The cardiopulmonary bypass, aortic across clamp, and circulatory arrest time was 162, 87, and 15 minutes, respectively. For securing a sufficient landing zone for stent graft implantation, the distal end of the hemashield graft was inserted into distal aortic arch as an elephant trunk. In our patient, the elephant trunk is attached to the proximal aorta arch after debranching and bypassing both common carotid arteries from the hemashield graft of ascending aorta in order to exclude dilated aorta arch distal to the origins of the left and right subclavian arteries ().\nThe second procedure was performed 14 days after the first procedure. Under general anesthesia, a left neck skin incision was made. Left common carotid and left subclavian arteries were exposed. A bypass surgery connecting common carotid artery and subclavian artery was performed using an 8 mm hemashield graft. A bypass surgery connecting the right common carotid artery with the subclavian artery was performed 6 days later as a third stage procedure because of fragile patient's condition after the surgery. After the closure of the incision site, the patient was placed under a fluoroscope. Both common femoral arteries are punctured. A 5 Fr marker pigtail catheter was inserted through the left femoral artery for the angiographic guidance. The right femoral artery was prepared for the later closure using two Perclose ProGlide suture closure devices (Abbott Vascular, Redwood City, CA, USA). Amplatz Vascular Plugs II (14 mm in diameter, AGA Medical Corporation, Golden Valley, MN, USA) were implanted into the right and the left subclavian artery using a 7 Fr shuttle sheath in order to prevent retrograde endoleaks into aortic aneurysm. A 0.035 inch extra stiff wire (Lunderquist, Cook Inc., Bloomington, IN, USA) was inserted through the right femoral artery into the ascending aorta. A 34×202 mm thoracic stent graft (Zenith TX2, Cook, Bloomington, IN, USA) was inserted over the wire and deployed within the hemashield graft implanted in the aortic arch. Stent grafts of appropriate size were not available from one vendor at that time. Therefore, an additional 40×100 mm stent graft (SEAL, S & G, Seoul, Korea) was implanted distal to the first stent graft in an overlap manner. A 40 mm balloon (Coda, Cook Inc., Bloomington, IN, USA) was used to appose the stent graft the aorta wall under rapid pacing. An immediate post-implant aortography showed no significant endoleak (). The right femoral artery access site was closed by tightening the knots prepared by Preclose technique without complication. At a CT taken before discharge, the aneurysm was completely excluded without significant endoleak. The patient was discharged in good status 5 days after the stent graft procedure and in the subsequent 2 years has remained well with no complications ().