Society For Clinical Vascular Surgery

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Right Sided Aortic Arch with Aneurysm: Operative Strategies for Hybrid Thoracic Endovascular Repair
Limael E. Rodriguez, Animesh Rathore, Suhas Bharadwaj, Justin Milligan, Jean M. Panneton
Eastern Virginia Medical School, Norfolk, VA

Objective
In this study, we evaluate the perioperative and intermediate term outcomes of patients with right sided aortic arch (RSAA) with aneurysmal disease that underwent thoracic endovascular aortic repair (TEVAR) in our practice.
Methods
A retrospective cohort study of all patients with CT confirmed RSAA with aneurysmal disease treated with TEVAR since August 2011 was performed. Demographic, periprocedural, and follow up data were collected for these patients. The primary endpoints were perioperative and intermediate term outcomes.
Results
A total of 5 patients had RSAA with aneurysm and/or dissection requiring repair. The mean age was 56 years (39-74), and majority were male (60%). All patients (5/5, 100%) had a preoperative CTA confirming the right sided arch and associated pathology. Overall, 3/5 patients underwent elective planned operation with one patient with dysphagia related to a large Kommerellís diverticulum (KD) and two patients with > 5cm non-ruptured TAA with a large KD. There were two patients with acute rupture and dissection requiring emergent repair. Most patients underwent a staged operation with single or bilateral subclavian bypass or transposition (3/5, 60%). One patient presenting with rupture was managed with total open arch replacement using an interposition multi-branched arch graft with an elephant trunk.
This patient developed a type II endoleak on postoperative day 12, which was managed percutaneously with coil embolization using left internal mammary artery access. The mean length of stay after TEVAR in the emergent group was significantly longer when compared to the elective patients (16.5 vs 2.7 days, p=0.02). At 30 days post op, there were no major adverse events or mortalities. At a mean follow up of 2 years (2-83 months), no patients had developed an endoleak or required redo operation.
Conclusion
RSAA with aneurysm and/or dissection requires special considerations for management. Cross-sectional imaging is an integral part of the workup to detect the anomalous anatomy. Staged repair with great vessel debranching, followed by TEVAR, has resulted in favorable perioperative and intermediate term outcomes.


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