Simplified Visceral Debranching With A Four-branched Graft Using Self-expanding Stent Grafts For Open Thoracoabdominal Aortic Aneurysm Repair
William J. Yoon, M.D., Victor M. Rodriguez, M.D..
University of California-Davis, Sacramento, CA, USA.
OBJECTIVES: For visceral debranching procedure during thoracoabdominal aortic aneurysm (TAAA) open repair, the use of a four-branched graft has emerged as an attractive alternative to the traditional patch reattachment due to the potential to avoid visceral aortic patch aneurysm. However, this four-branched graft approach includes the greater number of anastomoses that may not only take longer to complete than a single patch anastomosis leading to prolonged flow interruption, but may also increase the risk of anastomotic kinking during viscera derotation. We present a simplified debranching technique that alleviates the aforementioned drawbacks.
METHODS: Aortic reconstruction proceeds with a four-branched graft constructed on the back table. After institution of left-sided heart bypass, the aorta is clamped proximally in the chest and distally just above the aortic bifurcation, and transected proximal to the diseased segment. The aneurysm is then opened and T-d off. The proximal aortic anastomosis is performed first. A longitudinal graftotomy is then made on the main graft body opposite to the takeoff of the right renal branch. The right renal branch is trimmed. Two pledgeted stay sutures are placed in a U-fashion in the orifice of the right renal artery, and subsequently passed through the end of the right renal branch of the graft. Through the graftotomy, a self-expanding stent graft is advanced through the renal branch into the right renal artery over a guidewire. The stent is then deployed and balloon dilated, securing the distal end of the stent in the renal artery and the proximal end in the branch graft. Then, the celiac, superior mesenteric and left renal vessels are anastomosed using the same technique. The graftotomy is closed, and flow to the mesenteric and bilateral renals is initiated. The distal anastomosis is then created completing aortic reconstruction.
RESULTS: Deployment of a self-expanding stent graft into the visceral vessel and subsequent balloon dilation resulted in creation of an end-to-end visceral vessel-to-branch graft anastomosis without suturing. The operation time for the anastomosis is significantly shortened, resulting in a reduction in the ischemic time of viscera. The stent graft in the anastomosed branches prevents kinking or twisting of the revascularized vessel during viscera de-rotation.
CONCLUSIONS: This simple revascularization technique is technically feasible and time shortening in all visceral debranching cases, irrespective of visceral vessel anatomy.
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