Abstract Objective To investigate the application of surgical hybridization in the treatment of thoracic aortic disease involving supra-archival branches. Methods Forty-three cases of surgical hybridization were retrospectively analyzed from 1998 to 2008. Preoperative aortic arch angiography was performed, and the lesions were divided into three groups according to the degree of involvement of the supra-aortic branch arteries, and surgical techniques were applied to reconstruct the supra-aortic arteries, followed by endoluminal repair of the thoracic aorta. Results In all cases, the surgery was successfully completed, the stented vessels were successfully released, and the incidence of proximal type I endoleaks after endoluminal repair was 18.6% (8/43), with no symptoms of cerebral ischemia or severe upper limb ischemia. The 5-year involvement patency rate of the vascular grafts was 82%. Conclusion For thoracic aortic lesions involving supra-arch branches, surgical hybridization is currently a relatively safe and effective ideal procedure, and the long-term efficacy needs to be further observed.
Keywords: aorta; surgery; stent
Hybrid operation to treat thoracic aorta diseases involving the aortic arch
JIA Xin, GUO Wei, LIU Xiao-ping, YIN Tai, XIONG Jiang, ZHANG Hong-peng, ZHANG Guo-hua, LIANG Fa-qi Department of Vascular Surgery, PLA General Hospital Beijing 100853, China
Corresponding author: GUO Wei Email:[email protected]
Abstract Objective To investigate the hybrid treatments of thoracic aorta diseases involving supraaortic great vessels. All cases were divided into three groups according to the degree of aortic arch involvement. Different types of surgical reconstruction of supraarotic vessels were firstly underwent in all cases and then endovascular repair were completed. The hybrid procedures succeeded in all cases and the perioperational bypass graft patency were 100%. The short term type I endoleak rate were 18.6% (8/43). The accumulative 5 year patency of bypass graft were 82%. Conclusion Up to now, hybrid operation is a safe and effective procedure to treat complex The long term result still need more proof.
Key words aorta; surgical procedures; stents
Thoracic aortic diseases, mainly including thoracic aortic aneurysm (TAA) and thoracic aortic dissection (TAD), are catastrophic diseases that seriously endanger people’s health, and surgical management of thoracic aortic diseases involving the arch is very difficult. In this paper, we retrospectively analyzed 43 cases of thoracic aortic disease involving the aortic arch admitted and operated at our center from December 1998 to December 2008, hoping to guide future treatment.
Materials and Methods
Data
The total number of cases in this group was 43, 33 males and 10 females, with a mean age of 57.3 years (30-81 years). Among them, there were 29 cases of TAD, including 5 cases of Standford type A and 24 cases of type B entrapment; 14 cases of TAA. The concomitant diseases included hypertension in 37 cases, coronary artery disease in 26 cases, myocardial infarction in 9 cases, cerebral infarction in 11 cases, chronic cardiac insufficiency in 9 cases, chronic obstructive pulmonary disease in 13 cases, and chronic renal insufficiency in 19 cases.
According to the degree of lesion involvement in the aortic arch, we can divide them into three groups as follows: group A, lesion proximal involvement or distance less than 15 mm from the left subclavian artery, 20 cases; group B, lesion proximal involvement or distance less than 15 mm from the left common carotid artery, 19 cases; group C, lesion proximal involvement or distance less than 15 mm from the cephalobrachial trunk artery, 4 cases.
Methods
Preoperative and intraoperative assessment of cerebral perfusion: all cases underwent preoperative CT or MRI of the brain to initially understand whether there was a primary intracranial lesion; intraoperative imaging of the aorta and superior arch branches was performed first, followed by selective imaging of the bilateral carotid and vertebral arteries to assess the perfusion of the whole cerebral circulation. Matas test was also performed to understand the traffic condition of Willis ring in detail to guide the choice of surgical plan.
Surgical reconstruction of the superior arch branch arteries.
Group A: In most cases involving the left subclavian artery, direct intraluminal repair can be performed without reconstruction of the left subclavian artery. In this group, the right vertebral artery was found to be slender or dysplastic during the evaluation of cerebral arteriography. To avoid possible cerebral ischemia, the left subclavian artery was reconstructed surgically first, followed by intraluminal repair of the thoracic aorta to cover the opening of the left subclavian artery. The left subclavian artery was reconstructed as follows: 1) bilateral subclavian artery artificial vessel bypass with proximal ligation of the left subclavian artery; 2) lateral bypass of the left common carotid- left subclavian artery artificial vessel with proximal ligation of the left subclavian artery; 3) if the length of the left subclavian artery was found to be sufficient intraoperatively, direct left subclavian- left common carotid artery end-lateral anastomosis.
Group B: Surgical reconstruction of the left common carotid artery was performed as follows: right common carotid- left common carotid artery artificial vessel bypass; or right subclavian- left common carotid artery artificial vessel bypass with ligation of the proximal end of the left common carotid artery. The left subclavian artery was treated with the same principles as group A. After the completion of revascularization, endoluminal repair of the thoracic aorta was then performed to cover the left common carotid artery opening.
Group C: The endoluminal technique was applied to reconstruct or preserve the cephalobrachial trunk artery, and the surgical technique was applied to reconstruct the left common carotid artery and the left subclavian artery.
All artificial vessel grafts in this group were selected from GORETEX 8 mm diameter PTFE internal support ring vessels.
1.2.3 Arterial exposure and incision selection: the common carotid artery was exposed by a longitudinal or transverse incision on the anterior border of the ipsilateral sternocleidomastoid muscle, or the subclavian artery was exposed by a transverse incision on the ipsilateral clavicle.
1.2.4 Thoracic aortic endoluminal repair: after the completion of arterial revascularization of the superior arch branch, endoluminal repair of the thoracic aorta was performed, see literature 1, 2.
1.2.5 Follow-up: Follow-up by CTA was performed at 3, 6, 12 months after surgery and annually thereafter, scanning from the supra-aortic arch to the iliofemoral artery to observe the stent vessel morphology, pseudoluminal thrombosis, patency of the artificial vessel graft and endoleaks, as well as the occurrence of complications such as cerebral and upper limb ischemia.
Results
Postoperative results: All 20 patients in group A successfully reconstructed the left subclavian artery, including 9 cases with lateral artificial vessel bypass of the left common carotid- left subclavian artery, 7 cases with direct end-lateral anastomosis of the left subclavian- left common carotid artery, and 4 cases with bilateral subclavian artery artificial vessel bypass. 19 patients in group B successfully reconstructed the left common carotid artery. In group B, the left common carotid artery was reconstructed successfully in all 19 patients, and the procedure was performed by right common carotid- left common carotid artificial vessel bypass. 4 patients in group C were preserved or reconstructed by endoluminal technique of the cephalobrachial trunk artery, and then reconstructed by surgical technique of the superior arch branch artery. All stent vessels were successfully released with accurate positioning and 100% technical success rate, with no perioperative deaths. Thoracic aortic DSA angiography was performed immediately after the operation, and there were 8 cases of type I endoleaks in the proximal anchorage area of the stent, with an incidence of 18.6% (8/43), but due to the small amount of endoleaks, no further treatment was performed, and the patients were followed up after the operation. There was no postoperative cerebral ischemia or severe upper limb ischemia symptoms.
Follow-up results: 38 cases were followed up and 5 cases were lost, with a follow-up rate of 11.6%, and the follow-up time ranged from 1 month to 84 months, with an average of 39.3 months. 2 cases died suddenly during the follow-up period (14 and 34 months), excluding tumor rupture; 3 cases died of acute heart attack and 1 case died of gastric cancer metastasis. The 5-year cumulative patency rate of the reconstructed vascular grafts was 82%. Of the 8 cases with early postoperative type I endoleaks, 1 case was lost to follow-up, 5 cases disappeared after 3 months of follow-up, and 2 cases had persistent endoleaks with continued tumor growth at follow-up and underwent a second operation.
Discussion
Thoracic aortic coarctation and thoracic aortic aneurysm are very aggressive aortic diseases with high mortality. Endoluminal aortic repair has emerged in recent years as the preferred treatment option for this disease because of its minimal trauma and proven recent efficacy. The technical key of endoluminal repair is to ensure that the proximal end of the stent vessel should have an adequate anchorage area, but when the thoracic aortic lesion involves the aortic arch, it is a difficult problem to preserve the branch arteries on the arch and thus avoid affecting the normal blood supply to the brain and upper extremities.
Surgical hybridization technique, i.e., first reconstructing the supra-arch branch artery using surgical techniques to increase the proximal anchorage zone, and then applying endoluminal techniques to repair the thoracic aortic lesion, can well resolve the above-mentioned contradiction.3-5 The reconstruction method of the left subclavian artery in group A cases preferred left common carotid artery-left subclavian artery artificial vessel bypass, followed by self The vertebral artery was ligated medially to the proximal left subclavian artery. If the proximal end of the left subclavian artery is found to be long enough, the subclavian artery can also be transected from the vertebral artery and the proximal end of the left internal thoracic artery, ligated proximally, and the distal end turned over to perform a terminal anastomosis with the left common carotid artery. In group B, all cases were treated with a right common carotid artery-left common carotid artery artificial vessel bypass, with proximal ligation of the left common carotid artery and end-to-end anastomosis of the artificial vessel with the bilateral common carotid arteries. The artificial vessel tunnel is usually used as an anterior subcutaneous neck tunnel, which has the advantage of being less invasive and easy to apply, but may compress the trachea and affect the appearance of the neck for those with little subcutaneous fat due to the superficial location of the graft. To overcome these disadvantages, tunneling from the posterior tracheal space can also be used, which is more hemodynamic but more traumatic than the previous method. group C cases are those with lesions proximal to or less than 15 mm away from the cephalobrachial trunk artery. in this group, the cephalobrachial trunk artery was preserved by the endoluminal technique, and the left common carotid artery and left subclavian artery were reconstructed by the surgical technique. In addition to this, surgical reconstruction of the cephalobrachial trunk and other branches of the superior arch artery from the ascending aorta is also possible. However, this approach requires a median thoracic incision, with a corresponding increase in surgical trauma and perioperative risk.
In this group of cases, there was an 18.6% incidence of proximal type I endoleaks despite the addition of a proximal anchorage zone by surgical hybridization. The main reason was aortic calcification and tortuosity in the proximal aneurysmal neck region, which resulted in poor proximal apposition of the stent vessel to the aorta and thus type I endoleaks. In our opinion, to solve this problem, we need to start from the design of the product and increase the flexibility of the stent vessel body, and the better the flexibility, the lower the incidence of type I endoleaks in the proximal part of the stent vessel. In addition, the stent vessel body should cross the aortic arch isthmus as much as possible and release proximally because the aortic isthmus is the area where proximal type I endoleaks are most likely to occur. If the proximal endoleaks are not significant, they can be reviewed with regular follow-up. If endoleaks are found to persist and the aneurysmal lumen is growing, reoperation needs to be considered.