Combined surgical and endovascular treatment of aortic arch aneurysms

Background: Traditional repair of aortic arch aneurysms requires cardiopulmonary bypass, hypothermia, and circulatory arrest and is associated with considerable morbidity and mortality. Endovascular stent-graft placement has developed as a safe and effective treatment for various diseases of the descending aorta and, recently, even in delicate anatomic regions such as the aortic arch. The aim of this study is to review our clinical experience with endovascular treatment of aortic arch aneurysms after surgical transposition of supra-aortic vessels. Methods: Fifteen patients received thoracic stent-graft implants after aortic debranching for repair of aortic arch aneurysms during the 3-year period ending December 31, 2005. All patients were not candidates for standard endovascular repair due to inadequate proximal landing zones on the aortic arch. Device design and implant strategy were determined by an evaluation of aortic morphology with angiography and computed tomography (CT) scanning. Stent-grafts were used to repair the arch after supra-aortic vessel transposition was performed. The endografts were implanted transfemorally or via an iliac Dacron conduit graft using standardized endovascular techniques. Follow-up was 100% complete (mean, 18 +/- 2.5 months; range, 12 to 36 months). Outcome variables included death and treatment failure (endoleak, aortic rupture, reintervention, or aortic-related or sudden death). Follow-up included clinical examination, chest radiograph, and CT at discharge, 6 months after stent-graft placement, and yearly thereafter. Results: Stent-graft deployment success was 100% after staged supra-aortic vessel transposition. Patency of all endografts and conventional bypasses was 100%. No endoleak or graft migration was observed. There were no neurologic complications. One patient died 2 months after the procedure from pulmonary complications. Conclusion: Repair of aortic arch aneurysms by sequential transposition of the supra-aortic branches and endovascular stent-graft placement is feasible. Extended application of this technique will enable safe and effective treatment of a highly selected subgroup of patients with aortic aneurysms by avoiding conventional arch aneurysm repair in deep hypothermia and circulatory arrest.