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.