Safe guidance of hybrid stentgraft placement and emergency true lumen cannulation in aortic dissection by angioscopy

Objectives: Angioscopy is an almost forgotten technique lacking acceptance due to inability to look through blood. During hypothermic circulatory arrest (HCA) however, a briefly visible descending aorta is exposed, enabling direct vision to the surgeon. This study evaluated its impact on arch and descending aortic surgery for type A aortic dissection (AAD).

Methods: From 12/2007 to 08/2009, 29/40 patients underwent aortic surgery for acute (n=21) or chronic (n=8) AAD combined with intraoperative angioscopy. It was used to assure true lumen (TL) positioning of the arterial cannula during open vision aortic cannulation (OVAC; 11/29) and/or to inspect the arch and descending aorta for reentries, guide wire position and target zone for hybrid stentgraft landing. Thereafter, stentgraft unfolding was controlled. A sterilized flexible fiberscope was used in all cases.

Results: In all OVAC patients, angioscopy secured positioning of the arterial cannula within the TL. In 18/29 cases, no additional reentries were found thus obviating arch replacement in 4/29 and stentgrafting in 14/29. In 11/29 cases, stentgraft deployment was guided within the TL, in 3 cases incomplete unfolding initiated balloon dilatation, and in one case, an obstructed guide wire was clamp harvested into the TL. Additional HCA time was less than 2 minutes in all cases.

Conclusions: Angioscopy has become an indispensible tool for decision making in AD to apply OVAC, downstream stentgrafting, and landing zone control with the ability to indicate ballooning in case of incomplete unfolding at neglectable time requirements during HCA.