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OBJECTIVES: Conventional surgical repair of thoracic aortic dissections extending distally from proximal arch is still challenge to the surgeon. Mortality rates varies between 7 to 17 %.Lengthy procedures with cardiopulmonary bypass and hypothermic circulatory arrest periods also serve as a significant risk of morbidity including stroke
METHODS: 72 year-old man with chest and interscapular pain had thoracic aortic dissection with proximal tear at the proximal arch and a diameter of 70 mm at the level of isthmus extending as distally as iliac bifurcation with aberrant right subclavian artery. Our operative strategy included TEVAR with debranching of the supra-aoic vessels with bifurcated graft that was considered to avoid lengthy operational times and hypothermic arrest in addition to significant neurological risk due to presence of aberrant RSA. Proximal anastomosis of the 18/9 mm bifurcated dacron graft was employed on the proximal aorta with side-biting clamp. Distal anastomoses were performed in end-to-end fashion to bilateral carotid arteries. Left subclavian artery (LSA) originated from the aneurismal aortic segment and grafting from sternotomy was considered highly difficult and left carotico-subclavian bypass grafting was scheduled following debranching of the carotid arteries. As the TEVAR procedure was deemed to cover the arch to the isthmus, presence of an aberrant RSA would have led to blockage of both SA increasing the risk of paraplegia significantly, we scheduled left carotico-subclavian bypass just prior to TEVAR procedure next morning. 44 mm x20 cm Talent Endoluminal Stent-Graft was deployed to cover distal ascending aorta to the isthmus just following left carotico-subclavian bypass with a 8 mm ePTFE graft. Closure of the primary tear led to cessation of contrast filling of the false lumen. RSA received retrograde filling without any arm ischemia.
RESULTS: In our preliminary experience, inclusion of the, LSA was not possible as it was far too distant for a satisfactory anastomosis due to aneurysmal nature of the aorta and originated from the dissected tissue. Carotico-subclavian bypass for LSA was performed to avoid neurological events.Right carotico-subclavian bypass was avoided due to observation of adequate retrograde filling during control angiography and that no arm ischemia was observed
CONCLUSIONS: As more experience grew in TEVAR, more complex pathologies of the thoracic aorta such as arch dissections or type B dissections involving the arch were included in the endovascular surgeons’ armamentarium