Comment
Three options are available for the management of extensive arch
disease: (i) total arch replacement with the elephant trunk technique,
(ii) total endovascular intervention or (iii) hybrid repair. A total
arch replacement is a major intervention which requires the use of CPB
and circulatory arrest, and might not be suitable for patients with
unacceptable surgical risk. On the other hand, off-the-shelf arch
branched stent grafts are not yet widely available. In addition,
customized branched stent-grafts cannot be used in urgent scenarios.
Bearing those challenges in mind, we presented a hybrid technique used
to manage a pseudoaneurysm of the arch and which allowed for a total
debranching without the need for CBP or circulatory arrest.
This attractive option comes with its own sets of challenges. The main
difficulty is to secure a sufficient landing zone of at least 2 cm in
the ascending aorta while finding a healthy portion of aorta for the
side clamping. Some surgeons choose to institute CPB in cases where
partial clamping is too close to the level of the sinotubular
junction1. Another procedural variation is to do a
one-stage approach where the endovascular graft is placed in the same
setting, giving the option for antegrade deployment via transaortic
route2. While antegrade deployment reduces the
occurrence of type A retrograde ascending aortic dissection, it makes it
harder to negotiate the curvature of the arch angle and carries a risk
of iatrogenic type B dissection.
Osler’s statement on aneurysmal disease is certainly applicable to the
aortic arch; arch disease is very humbling. The smoothest surgery
sometimes leads to devastating and unforeseen neurological
complications. There is no good or bad operation, only a more favorable
option which stays in line with the patient’s risk profile, values and
preferences. Indeed, the goal of surgery is not only to have an alive
patient but to also maximize their neurologic and metabolic recoveries.
As with any complex surgical case, careful preoperative planning is of
the essence and should include a multidisciplinary discussion by a
specialized thoracic aortic team. Criteria for patient selection should
include their level of care, age, surgical risk, level of frailty,
extent of their peripheral vascular disease, as well as the
interpretation of the arch anatomy and landing zone determination.
In conclusion, this case illustrates a hybrid repair of an extensive
arch disease which allows for total debranching without the use of CPB
or circulatory arrest, thereby potentially carrying a lower mortality
and morbidity. This safe and reproducible procedure can provide
favorable results and remains an attractive option in patients
considered unfit for conventional total arch replacement or in centers
where total endovascular interventions are not feasible. We believe this
technique deserves more attention, especially as the elderly population
is experiencing rapid growth. Longer term radiographic and clinical
follow-up are needed to evaluate the full merits of this approach.