Use of On-Site Digital Subtraction Angiography for Left Subclavian Artery Management During Hybrid Aortic Arch Repair in DeBakey I Dissection

Abstract

Purpose:

A hybrid aortic repair using the frozen elephant trunk (FET) technique with an open distal anastomosis in zone 2 and debranching of the left subclavian artery (LSA) has been demonstrated to be favorable and safe. Although a transposition of the LSA reduces the risk of cerebellar or medullar ischemia, this may be challenging in difficult LSA anatomies.

Case Report:

We present the case of a 61-year old patient with DeBakey I aortic dissection, treated with FET in moderate hypothermic circulatory arrest (26°C) and selective cerebral perfusion using a Thoraflex-Hybrid (Vascutek Terumo) prosthesis anchored in zone 2, with overstenting of the LSA orifice and no additional LSA debranching. Sufficient perfusion of the LSA was proved intraoperatively using LSA backflow analysis during selective cerebral perfusion in combination with on-site digital subtraction angiography (ARTIS Pheno syngo software). No neurologic dysfunction or ischemia occurred in the postoperative course. An angiographic computed tomography revealed physiologic LSA perfusion, with subsequent thrombotic occlusion of the false lumen in the proximal descending aorta after 7 days.

Conclusion:

Using an angiography-guided management in patients with complex DeBakey I dissection and difficult anatomy may simplify a proximalization of the distal anastomosis in zone 2 for FET, even without an additional LSA debranching.

Keywords

digital subtraction angiography frozen elephant trunk aortic arch replacement left subclavian artery aortic dissection

Get full access to this article

View all access options for this article.

References

Di Bartolomeo

Pacini

Savini

, et al. Complex thoracic aortic disease: single-stage procedure with the frozen elephant trunk technique. J Thorac Cardiovasc Surg. 2010;140(suppl 6):S81-S85; discussion S86–S91.

Mitchell

Ishimaru

Ehrlich

, et al. First international summit on thoracic aortic endografting: roundtable on thoracic aortic dissection as an indication for endografting. J Endovasc Ther. 2002;9(suppl 2):II98–II105.

Shrestha

Kaufeld

Beckmann

, et al. Total aortic arch replacement with a novel 4-branched frozen elephant trunk prosthesis: single-center results of the first 100 patients. J Thorac Cardiovasc Surg. 2016;152(1):148–159. doi:10.1016/j.jtcvs.2016.02.077.

Hage

Ginty

Power

, et al. Management of the difficult left subclavian artery during aortic arch repair. Ann Cardiothorac Surg. 2018;7(3):414–421. doi:10.21037/acs.2018.03.14.

Misfeld

Borger

. Surgical strategies for zone 2/3 pathologies of the thoracic aorta: resolve or prepare? J Thorac Cardiovasc Surg. 2018;155:2299–2300.

Leone

Di Marco

Coppola

, et al. Open distal anastomosis in the frozen elephant trunk technique: initial experiences and preliminary results of arch zone 2 versus arch zone 3. Eur J Cardiothorac Surg. 2019;56:564–571.

Cui

Han

, et al. Selective left subclavian ligation in total aortic arch replacement. Ann Thorac Surg. 2012;93:110–114.