Transaortic Stent Grafting for Distal Arch Aneurysm with Antegrade and Retrograde Extracorporeal Circulation

Abstract

Purpose: The purpose of this study was to determine whether cerebrospinal cord injury can be avoided with transaortic stent grafting for distal aortic aneurysm, and whether this technique can be widely used.

Methods: Seventeen patients underwent distal aortic aneurysm repair with the transaortic stent grafting technique. All patients had a median sternotomy with combined antegrade and retrograde perfusion and selective cerebral perfusion. The stent graft was inserted via an aortotomy at the aortic arch. We evaluated the aneurysms on computed tomography scan 2 weeks and 3 months after surgery.

Results: The follow-up period ranged from 3 to 85 months. There was no operative mortality or cerebrospinal dysfunction. Reoperation was performed in two patients. One patient died 15 days after the second operation. Postoperative computed tomography scan showed early thrombosis of the excluded aneurysmal space in 15 (88.2 %) patients.

Conclusion: Cerebrospinal cord injury could be avoided by selecting lesions for indications and using a combination of antegrade and retrograde perfusion. This surgical technique is useful for arch aneurysms and can be widely used.

Key words

transaortic stent grafting - distal arch aneurysm - antegrade and retrograde perfusion - cerebrospinal cord injury

References

• 1 Kawahito K, Adachi H, Ino T. Anterolateral thoracotomy for distal aortic arch disease.  Surg Today. 2005;  35 924-934
• 2 Minatoya K, Ogino H, Matsuda H, Sasaki H, Yagihara T, Kitamura S. Surgical management of distal arch aneurysm: another approach with improved results.  Ann Thorac Surg. 2006;  81 1353-1357
• 3 Czerny M, Zimpfer D, Fleck T, Hofmann W, Schoder M, Cejna M. et al . Initial results after combined repair of aortic arch aneurysm by sequential transposition of the supra-aortic branches and consecutive endovascular stent-graft placement.  Ann Thrac Surg. 2004;  78 1256-1260
• 4 Criado F J, Clark N S, Barnatan M F. Stent graft repair in the aortic arch and descending thoracic aorta: a 4-year experience.  J Vasc Surg. 2002;  36 1121-1128
• 5 Kato N, Ohnishi K, Kaneko M, Ueda T, Kishi D, Mizushima T. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft.  Circulation. 1996;  94 (Suppl. 2) 188-193
• 6 Stone D H, Brewster D C, Kwolec C J, LaMuraglia G M, Conrad M F, Chung T K. et al . Stent-graft versus open-surgical repair of the toracic aorta: mid-term results.  J Vasc Surg. 2006;  44 1188-1197
• 7 Sueda T, Orihashi K, Okada K, Sugawara Y, Imai H, Hamamoto M. Successful shrinkage of distal arch and proximal descending aortic aneurysm after transaortic endovascular stent-grafting.  Eur J Cardiothorac Surg. 2004;  25 716-721
• 8 Usui A, Fujimoto K, Ishiguchi T, Yoshikawa M, Akita T, Ueda Y. Cerebrospinal dysfunction after endovascular stent-grafting via median sternotomy: the frozen elephant trunk procedure.  Ann Thorac Surg. 2002;  74 1821-1824
• 9 Flores J, Kunihara T, Shiiya N, Yoshimoto K, Matsuzaki K, Yasuda K. Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury.  J Thorac Cardiovasc Surg. 2006;  131 336-342
• 10 Kieffer E, Richard T, Chiras J, Godet E, Cotmier E. Preoperative spinal cord arteriography in aneurysmal disease of the descending thoracic and thoracoabdominal aorta preliminary results in 45 patients.  Ann Vasc Surg. 1989;  3 33-46
• 11 Williams G M, Perler B A, Burdick J F, Ostermann Jr F A, Mitchell S, Merine D. et al . Angiographic localization of spinal cord blood supply and its relationship to postoperative paraplegia.  J Vasc Surg. 1991;  13 23-33
• 12 Jacobs M J, deMol B A, Elenbaas T, Mess W H, Kalkman C J, Schurink G W. et al . Spinal cord blood supply in patients with thoracoabdominal aortic aneurysm.  J Vasc Surg. 2002;  35 30-37
• 13 Amabile P, Grisoli D, Giorgi R, Bartoli J M, Piquet P. Incidence and determinants of spinal cord ischaemia in stent-graft repair of the thoracic aorta.  Eur J Vasc Endovasc Surg. 2007;  35 455-461
• 14 Baraki H, Hagl C, Khaladj N, Kallenbach K, Weidemann J, Haverich A. et al . The frozen elephant trunk technique for treatment of thoracic aortic aneurysms.  Ann Thorac Surg. 2007;  83 s819-s823
• 15 Zipfel B, Hammerschmidt R, Krabatsch T, Buz S, Weng Y, Hetzer R. Stent-grafting of the thoracic aorta by the cardiothoracic surgeon.  Ann Thorac Surg. 2007;  83 441-449
• 16 Gorlitzer M, Weiss G, Thalmann M, Mertikian G, Wislocki W, Meinhart J. et al . Combined surgical and endovascular repair of complex aortic pathologies with a new hybrid prosthesis.  Ann Thorac Surg. 2007;  84 1971-1976