References
Szeto WY, Bavaria JE, Bowen FW, Woo EY, Fairman RM, Pochettino A. The hybrid total arch repair: brachiocephalic bypass and concomitant endovascular aortic arch stent graft placement. J Card Surg . 2007;22(2):97-104.
Ghazy T, Mashhour A, Schmidt T, et al. Off-Pump Debranching and Thoracic Endovascular Aortic Repair for Aortic Arch Pathology. Innovations (Phila). 2015;10(3):163-169.
Figure 1. Preoperative 3D reconstruction obtained from computed tomography angiogram of the chest showing a pseudoaneurysm located at the inferior-posterior wall of the aortic isthmus, in anterior (A) and posterior (B) views.
Figure 2. Schematic illustration and intraoperative pictures (anesthetist view). A and B, Exposure of the ascending aorta and head vessels; C, A plaque-free portion of the ascending aorta is clamped tangentially using a partial side-biting clamp, followed by longitudinal arteriotomy; D, Completed end-to-side anastomosis of the main graft limb to the ascending aorta; E, Anastomosis of the middle graft limb to the distal end of the left common carotid artery. Each proximal arterial stump is ligated to prevent a type II endoleak (white arrow); F, Final result of the procedure. Metal clips were circumferentially placed 2 cm above the proximal aorta-to-graft anastomotic line to allow determination of the endoprosthesis landing zone in the second stage of the procedure (white arrows). 1, ascending aorta; 2, left brachiocephalic vein; 3, left common carotid artery; 4, innominate artery; 5, limb graft elongating the left subclavian artery distally.
Figure 3. Final result of the two-stage procedure in 3D reconstruction obtained from a computed tomography angiogram of the chest showing the supra-aortic vessels being rerouted to the ascending aorta and the proper position of the aortic stent with proximal landing in zone 0, excluding the pseudoaneurysm from the aortic lumen, in left anterior (A) and right posterior (B) views.