Technique for branched thoracic stent-graft repair of a chronic type A aortic dissection in a patient with multiple prior sternotomies

Erin H. Murphy, J. Michael DiMaio, Michael E Jessen, Frank R. Arko

Research output: Contribution to journalArticle

10 Scopus citations

Abstract

Purpose: To present a technique for endovascular treatment of a type A aortic dissection in a patient with multiple prior sternotomies and multiple medical comorbidities. Technique: The method is illustrated in a 76-year-old man with a history of hypertension, hyperlipidemia, coronary artery disease, and open repair of a type A aortic dissection via a median sternotomy. The latter procedure was complicated by a pericardial effusion requiring drainage and sternal re-wiring. The diameter of the residual type A dissection beginning just distal to the aortic root had increased by 1.5 cm over 1 year, indicating the need for further intervention. To avoid redo sternotomy, a hybrid endovascular approach was planned, but it would require landing the stent in the ascending aortic arch, thus mandating branch vessel revascularization. Prior to stent-graft deployment, right-to-left carotid-carotid and left carotid-subclavian artery bypasses were performed with 8-mm polytetrafluoroethylene grafts. Three Talent grafts were deployed from the celiac artery to the left subclavian artery. A pre-wired homemade branched Talent stent-graft (34x34x115 mm) was used to revascularize the innominate artery and secure the arch. Transvenous ventricular pacing was used to improve deployment accuracy. A 10x38-mm iCast stent was placed through the branch and extended into the innominate artery. The subclavian artery was occluded with 2 Amplatzer plugs. Postoperative computed tomography demonstrated excellent proximal fixation, a widely patent branched graft to the innominate artery, and thrombosis of the aneurysmal false lumen. Conclusion: Treatment of type A dissections remains a difficult surgical challenge. The approach taken should be tailored for each patient. We successfully employed a combination of available minimally invasive techniques to treat a patient who was not ideally suited to any of the individual strategies.

Original languageEnglish (US)
Pages (from-to)359-364
Number of pages6
JournalJournal of Endovascular Therapy
Volume18
Issue number3
DOIs
StatePublished - Jun 1 2011

Keywords

  • Aortic arch dissection
  • Hybrid endovascular repair
  • Innominate artery
  • Left subclavian artery
  • Stent-graft
  • Sternotomy
  • Supra-aortic branches
  • Type A dissection

ASJC Scopus subject areas

  • Surgery
  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine

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