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

9 Citations (Scopus)

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 2011

Fingerprint

Sternotomy
Stents
Dissection
Brachiocephalic Trunk
Thorax
Subclavian Artery
Transplants
Aptitude
Celiac Artery
Endovascular Procedures
Pericardial Effusion
Polytetrafluoroethylene
Hyperlipidemias
Thoracic Aorta
Carotid Arteries
Comorbidity
Coronary Artery Disease
Drainage
Thrombosis
Tomography

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

  • Cardiology and Cardiovascular Medicine
  • Radiology Nuclear Medicine and imaging

Cite this

Technique for branched thoracic stent-graft repair of a chronic type A aortic dissection in a patient with multiple prior sternotomies. / Murphy, Erin H.; DiMaio, J. Michael; Jessen, Michael E; Arko, Frank R.

In: Journal of Endovascular Therapy, Vol. 18, No. 3, 06.2011, p. 359-364.

Research output: Contribution to journalArticle

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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.",
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