Hybrid Surgical Approach in the Treatment of Iatrogenic IMH after Hemiarch Replacement
Abdullah Alfawaz, MD RPVI1, Tareq Massimi, MD2.
1Medstar Washington Hospital Center / Georgetown University, Washington, DC, USA, 2Medstar Washington Hospital Center, Washington, DC, USA.
DEMOGRAPHICS: 71 year old African American female with a history of hypertension and atrial fibrillation, on Apixaban, who recently underwent a Hemiarch replacement for an ascending aortic aneurysm two months prior to presentation.
HISTORY: She presented to the ER with chest pain radiating to the back and elevated blood pressure. CT Angiogram showed extensive aortic intramural hematoma extending from the repair to the visceral segment. Her symptoms did not subside despite blood pressure control and repair was planned.
PLAN: She was taken to the operating room and an endograft was deployed covering the left subclavian artery and extended to the level of the celiac artery. No lumbar drain placed or subclavian revascularization due to the patient being therapeutically anticoagulated with Apixaban. Post operatively, the patient continued to have persistent chest pain and imaging showed a type 1a endoleak. Consultation with cardiac surgery ended with a consensus that the patient is not a candidate for a redo sternotomy nor an open reconstruction. The patient was then taken to the OR for a hybrid surgical repair. A lumbar drain was placed. Right carotid to left subclavian bypass with transposition of the left carotid onto the bypass graft were performed. Unilateral Femoral and right carotid arteries were accessed for zone 0 thoracic endograft deployment and an Innominate stent graft snorkel. There was resolution of the endoleak intra-op and symptoms post op. The patient was discharged to a rehab facility in good condition.
DISCUSSION: Hybrid surgical approaches in treating proximal descending and arch aortic pathologies. Surgical technical considerations for aortic arch parallel endografting and in patients with prior aortic reconstructions.
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