O-234 - FROM THE AORTIC ROOT TO THE RENAL ARTERIES: STAGED HYBRID REPAIR OF AN EXTENSIVE THORACOABDOMINAL AORTIC ANEURYSM SECONDARY TO CHRONIC AORTIC DISSECTION

TOPIC:
Case Reports
AUTHORS:
Martinez Del Carmen D.T. (Hospital Universitari de Bellvitge ~ L'Hospital de Bellvitge ~ Spain) , Iborra Ortega E. (Hospital Universitari de Bellvitge ~ L'Hospital de Bellvitge ~ Spain) , Toral Sepulveda D. (Hospital Universitari de Bellvitge ~ L'Hospital de Bellvitge ~ Spain) , Vila Coll R. (Hospital Universitari de Bellvitge ~ L'Hospital de Bellvitge ~ Spain)
Introduction:
About 20% to 40% of aortic dissections develop aneurysmal degeneration, frequently on thoracoabdominal aneurysm (TAAA)1-2. Open repair of extensive TAAAs (Crawford extent I or II) is associated with high morbidity and mortality2-5. A less invasive hybrid approach has been proposed to improve postoperative outcomes 5-8. We report a complex case of an extensive thoracoabdominal aortic aneurysm with aortic root aneurysm secondary to chronic aortic dissection that required a multi-staged hybrid repair.
Methods:
Forty-three-year-old female with a history of hypertension was operated on for type A aortic dissection in November 2012. Cardiac surgeons replaced the ascending aorta with a 26mm Dacron and performed an aortic valve resuspension with hypothermic cardiocirculatory arrest. Seven years later, the angioCT showed proximal anastomosis aneurismal degeneration secondary to a chronic dissection of the right coronary sinus. There was also a growing aneurysm of the descending thoracic aorta. We proposed a staged repair.
Results:
In the first stage, we planned the proximal repair. Cardiac surgeons replaced the supra-coronary ascending aorta and the aortic arch by performing the frozen elephant trunk technique using an E-vita Open Neo Trifurcated endoprosthesis® (26/24x175 mm). They reimplanted the innominate artery and the left carotid artery. It was deemed impossible to revascularize the left subclavian artery. The aortic root repair consisted of resection of the right coronary sinus and plasty with Teflon stripes, aortic valve replacement with mechanical prosthesis and saphenous vein aortocoronary bypass to the right coronary artery. The patient was discharged after an uneventful postoperative process. Six months later, we performed the second stage. We performed a left carotid-subclavian bypass with 8 mm ringed PTFE and implanted a Thoracic Custom Made Device Cook® 28x200 covering from the E-vita Open Neo Trifurcated, to the diaphragmatic aorta. After a week, the patient was discharged home without incident. Two months later, we performed the third and last stage. A left thoracic-phreno-laparotomy approach was performed from the eighth intercostal space. Under hypothermic cardiocirculatory arrest, we anastomosed a Coselli prosthesis to the distal edge of the Cook device. The distal anastomosis was performed at the level of renal arteries avoiding renal bypass. WE opened the distal lamella to promote distal flow. The celiac trunk and superior mesenteric artery received a Coselli branch each. Finally, one of Coselli's branches was anastomosed to lumbar arteries at the level of L1. The patient was discharged after 13 days of an uneventful postoperative process.
Conclusion:
Staged hybrid repair with a proximal endovascular thoracic stent graft and distal open repair is safe for patients with chronic aortic dissection and aneurysm degeneration 2-6. TEVAR, as the first procedure, can be performed with minimal morbidity and allows patients to progress to the second open stage repair. It also provides time for the spinal cord perfusion collateral networks to develop from the subclavian and hypogastric arteries and aortic remodelling 2, 5-10. Using a staged hybrid repair, we combined well-established endovascular skills and technology with traditional open aortic surgical techniques to achieve good clinical results.
References:
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