Stentgraft Repair Of Aortic Arch Pathology

Introduction and Objectives:
Stentgraft repair of aortic arch disease may decrease morbidity compared to standard open repair. We review our initial experience with this technique.
Methods:
We performed a retrospective case series review of all patients undergoing aortic arch stent graft placement.
Results:
15 aortic arch stentgrafts were placed between July 2005 and April 2006. Arch pathology was aneurysm (6), dissection with aneurysm (5), dissection with branch vessel compromise (1), and transection (3). Procedures were urgent/emergent in 8 (1 with visceral ischemia and 7 with contained ruptures), and elective in 7. Six were considered unfit for standard open repair. Cardiopulmonary bypass was employed in 6. Antegrade deployment was performed in 3 (2 via ascending aorta, 1 via left ventricular apex). Debranching bypass procedures included aorto-inominate (3), aorto-left CCA (5), aorto-right CCA (2), aorto-right SCA (1), right CCA-SCA (1), CCA-CCA (2), right axillo-femoral (3), and left axillo-femoral in 1 patient with an internal mammary graft and unstable c-spine fracture. Only 1 patient underwent concomitant revascularization of the left SCA. 2 underwent post-operative left SCA revascularization for arm ischemia (1 likely due to embolism). There were 3 perioperative deaths (all emergent), 1 due to multisystem organ failure after trauma, 1 incomplete exclusion of a mycotic pseudoaneurysm, and 1 ruptured retrograde type A dissection after repair of acute complicated type B dissection. Major complications were seen in 3 of 12 survivors including multifocal stroke (1), subarachnoid hemorrhage (1), prolonged ventilatory support (2), renal failure (1), bleeding (1), and arm ischemia requiring subclavian revascularization (2). Endoleak persisted in 1 (not a candidate for further open surgery).
Conclusions:
Stentgraft repair of complex aortic arch pathology may be performed successfully with a variety of arch debranching procedures with acceptable morbidity and mortality, and may allow treatment of patients otherwise deemed inoperable.