Management of left subclavian artery in total arch replacement and frozen elephant trunk procedure

Abstract

Central MessageThe 20-mm cuff–to–last branch distance in E-vita OPEN NEO facilitates left subclavian artery anastomosis and the overall graft orientation in total arch replacement with frozen elephant trunk.See Commentaries on pages 41 and 43. The 20-mm cuff–to–last branch distance in E-vita OPEN NEO facilitates left subclavian artery anastomosis and the overall graft orientation in total arch replacement with frozen elephant trunk. See Commentaries on pages 41 and 43. The advent of frozen elephant trunk (FET) revolutionized open surgical management of total aortic arch aneurysm disease.1Leone A. Beckmann E. Martens A. Di Marco L. Pantaleo A. Bacchi Reggiani L. et al.Total aortic arch replacement with frozen elephant trunk technique: results from two European institutes.J Thorac Cardiovasc Surg. 2020; 159: 1201-1211Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar,2Berger T. Weiss G. Voetsch A. Arnold Z. Kreibich M. Rylski B. et al.Multicentre experience with two frozen elephant trunk prostheses in the treatment of acute aortic dissection.Eur J Cardiothorac Surg. 2019; 56: 572-578Crossref PubMed Scopus (24) Google Scholar However, one of the challenges is the left subclavian artery (LSA) anastomosis, which is often deep and difficult to visualize. The emerging use of E-vita OPEN NEO (JOTEC, Hechingen, Germany) is a promising approach to tackling this challenge. We report our early experience and describe the advantages of its design in facilitating anastomosis of the LSA. The new arch branched graft E-vita OPEN NEO was introduced to our center in October 2020. Between October and November 2020, 3 patients underwent total arch replacement using FET with the branched version of E-vita OPEN NEO. The operations were elective, the pathology was type III aortic dissection with arch aneurysm, and none had undergone previous aortic surgery. Perioperative data were collected retrospectively from institutional database with the patients' informed consent (Table 1). Mean operative time and circulatory arrest time were 315 ± 79 minutes and 47 ± 2 minutes, respectively. Selective antegrade cerebral perfusion (SACP) was delivered to all 3 supra-aortic branches during the procedure, and the mean SACP time was 138 ± 1 minutes. The mean hospital length of stay was 10 ± 1 days. No permanent spinal or neurologic complications or injury to the recurrent laryngeal nerve were observed. There was no in-hospital mortality.Table 1Perioperative data of the initial experience of E-vita OPEN NEOCharacteristicPatient 1Patient 2Patient 3Mean ± SDAge, y604672SexFemaleFemaleMalePathologyArch aneurysm with type III aortic dissectionPrevious aortic surgeryNoNoNoOperative time, min420295230315 ± 79CPB time, min195196173188 ± 11Cross-clamp time, min1011197398 ± 19MHCA time, min45504547 ± 2ACP∗All patients had selective ACP to all 3 supra-aortic branches. time, min137138139138 ± 1LSA anastomotic techniqueAxillary bypassExtension techniqueDirect anastomosisResternotomy for hemostasisNoNoNoTotal transfusion, units Packed cells233 Platelet concentrate666 Plasma233 Cryoprecipitate666StrokeNoNoNoParaplegiaNoNoNoHoarsenessNoNoNoPostoperative dialysisNoNoNoICU stay, d211Hospital stay, d1210910 ± 1Survival for 30 dYesYesYesEndoleakNoNoNoSD, Standard deviation; CPB, cardiopulmonary bypass; MHCA, moderate hypothermic circulatory arrest; ACP, antegrade cerebral perfusion; LSA, left subclavian artery; ICU, intensive care unit.∗ All patients had selective ACP to all 3 supra-aortic branches. Open table in a new tab SD, Standard deviation; CPB, cardiopulmonary bypass; MHCA, moderate hypothermic circulatory arrest; ACP, antegrade cerebral perfusion; LSA, left subclavian artery; ICU, intensive care unit. We previously reported our approach to total arch replacement using FET.3Ho J.Y.K. Chow S.C.Y. Kwok M.W.T. Fujikawa T. Wong R.H.L. Total aortic arch replacement and frozen elephant trunk.Semin Thorac Cardiovasc Surg. November 9, 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Using the novel device, we adopted the distal-proximal-supra-aortic sequence of anastomosis, under diastolic cardiac arrest, moderate hypothermic circulatory arrest between 25oC and 28oC, and SACP to all 3 supra-aortic vessels. In all cases, the left subclavian artery was perfused with antegrade cerebral perfusion during circulatory arrest and before revascularization. It was the first revascularized supra-aortic branch after the proximal aortic anastomosis. Two patients had deployment of FET with a 0.035” guidewire passed through a 5 Fr arterial sheath at the right common femoral artery under fluoroscopic guidance in the hybrid theatre. On-table angiography and transesophageal echocardiography confirmed satisfactory stent opening and no aortic injury. The 3 patients in this series had 3 different orientations of the supra-aortic branches (Figure 1), hence the variation in LSA anastomotic strategies, including direct anastomosis, extension technique, and left axillary artery extra-anatomic bypass (Video 1). When the LSA had a favorable exposure (Figure 1, A-1 and A-2), direct anastomosis was feasible, and the orientation of the postoperative computed tomography (CT) aortogram showed satisfactory results (Figure 2, A-1 and A-2). Figure 1, B-1 shows a more commonly presented orientation in which the LSA was found deeper into the mediastinum (Figure 1, B-2), with an extension of the LSA required for better exposure. The extension of the LSA was done with a segment of the 10-mm branched graft from the E-vita OPEN NEO on circulatory arrest (Figure 2, B-1). After stent deployment into the descending aorta and distal anastomosis, the LSA anastomosis was completed with a graft-to-graft anastomosis (Figure 2, B-2).Figure 2Intraoperative photos and computed tomography reconstruction of total aortic arch replacement with frozen elephant trunk with the variations of left subclavian artery (LSA) anastomosis considering the different origins. ˆ and ∗ denote the LSA anastomosis. The panels are presented in pairs with (A-2), (B-2), and (C-2) the 3-dimensional reconstructions of (A-1), (B-1), and (C-1), respectively. LSA anastomosis was performed with direct anastomosis (A-1), extension technique (B-1), and left axillary extra-anatomic bypass (C-1).View Large Image Figure ViewerDownload (PPT) On rarer occasions (as in Figure 1, C-1 and C-2), the LSA was not only deep, but also apically located, an extra-anatomic bypass of the left axillary artery and ligation of the LSA origin was required. The left axillary artery bypass was performed with a 6-mm graft under an infraclavicular incision. After stent deployment into the descending aorta and distal anastomosis, the vascular graft was tunneled through the first intercostal space and the left pleural cavity to reach the mediastinum for anastomosis with the 8-mm side branch of the E-vita OPEN NEO (Figure 2, C-1 and C-2). Internal ligation of the LSA origin was done with transfixing pledgeted sutures. The postoperative CT aortogram showed patent supra-aortic branches with satisfactory orientations without kinking of grafts (Figure 2, C-2). In total arch replacement with FET, zone 2 anastomosis has been associated with improved survival.4Tsagakis K. Jakob H. Which frozen elephant trunk offers the optimal solution? Reflections from Essen group.Semin Thorac Cardiovasc Surg. 2019; 31: 679-685Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 5Tsagakis K. Dohle D. Benedik J. Lieder H. Jakob H. Overall Essen's experience with E-vita open hybrid stent graft system and evolution of surgical technique.Ann Cardiothorac Surg. 2013; 2: 612-620PubMed Google Scholar, 6Xiao Z. Meng W. Zhu D. Guo Y. Zhang E. Treatment strategies for left subclavian artery during total arch replacement combined with stented elephant trunk implantation.J Thorac Cardiovasc Surg. 2014; 147: 639-643Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 7Tsagakis K. Shehada S.E. Dimitriou A.M. Mourad F. Osswald A. Wendt D. et al.Fate of extra-anatomic aortoaxillary bypass for facilitation of frozen elephant trunk surgery in zone 2: midterm results.Thorac Cardiovasc Surg. 2020; 68: S1-S72PubMed Google Scholar However, this approach is fraught with technical challenges, as the LSA can be deep and thus challenging, and various approaches and decision algorithms have been described.6Xiao Z. Meng W. Zhu D. Guo Y. Zhang E. Treatment strategies for left subclavian artery during total arch replacement combined with stented elephant trunk implantation.J Thorac Cardiovasc Surg. 2014; 147: 639-643Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 7Tsagakis K. Shehada S.E. Dimitriou A.M. Mourad F. Osswald A. Wendt D. et al.Fate of extra-anatomic aortoaxillary bypass for facilitation of frozen elephant trunk surgery in zone 2: midterm results.Thorac Cardiovasc Surg. 2020; 68: S1-S72PubMed Google Scholar, 8Hage A. Ginty O. Power A. Dubois L. Dagenais F. Appoo J.J. et al.Management of difficult left subclavian artery during aortic arch repair.Ann Cardiothorac Surg. 2018; 7: 414-421Crossref PubMed Scopus (11) Google Scholar The 3 approaches to LSA anastomosis described here allow better planning for full restoration of the supra-aortic branches, including the anticipated approach to achieve proximal control for anastomosis with good hemostasis in our experience. The 20-mm distance between the sewing collar and the third-side branch of the E-vita OPEN NEO offers a wider anastomotic space to the LSA and reduces the risk of kinking. https://www.jtcvstechniques.org/cms/asset/b41760f6-c160-4ad5-a201-ed2e10f54ee5/mmc1.mp4Loading ... Download .mp4 (104.07 MB) Help with .mp4 files Video 1Early experience with the E-vita OPEN NEO branched device for total aortic arch replacement with frozen elephant trunk, and surgical video on approaches to left subclavian artery anastomosis. Video available at: https://www.jtcvs.org/article/S2666-2507(21)00269-8/fulltext. Download .jpg (.02 MB) Help with files Video 1Early experience with the E-vita OPEN NEO branched device for total aortic arch replacement with frozen elephant trunk, and surgical video on approaches to left subclavian artery anastomosis. Video available at: https://www.jtcvs.org/article/S2666-2507(21)00269-8/fulltext.