Intraoperative Fenestration of Frozen Elephant Trunk (FET) and Total Arch Replacement for Aortic Dissection in Aberrant Subclavian Artery

Authors

  • Jing Zhang Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
  • Zhefeng Kang Department of Cardiovascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
  • Zejun Fei Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
  • Yuanyuan Fan West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, China
  • Yingqiang Guo Department of Cardiovascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
  • Jun Shi Department of Cardiovascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China

DOI:

https://doi.org/10.1532/hsf.4883

Keywords:

Aberrant, subclavian, aortic dissection, fenestration

Abstract

Background: Total arch replacement (TAR) and the frozen elephant trunk (FET) routinely are performed to treat aortic dissection. When aortic dissection combines with the aberrant right subclavian artery (aRSA), routine TAR+FET will occlude the ostium of aRSA. But there is no consensus regarding the optimal surgical strategy to revascularize the aRSA. We seek an uncomplicated and less time-intensive way to reconstruct the aRSA.

Methods: From July 2020 to April 2022, six patients with aortic dissection and aRSA underwent TAR+FET and intraoperative fenestration on the descending trunk. The mean age of the patients was 51.7 (SD 16.2; range 30.0–72.0). TAR+FET was performed via a median sternotomy and under cardiopulmonary bypass (CPB) and moderate hypothermic circulatory arrest (HCA). A fenestra of descending trunk was made intraoperative.

Results: There was no operative death in hospital and follow up. The average aortic cross-clamp time, SACP time, and lower body circulatory arrest time was 138.8 (SD 22.5; range 103.0–156.0) min and 28.3 (SD 3.9; range 25.0–35.0) min. Bleeding, neurological deficit, visceral ischemia, injury to the spinal cord, or organ dysfunction was not observed. Follow-up CTA showed the blood flow of aRSA was patent in all patients.

Conclusion: TAR+FET and intraoperative fenestration on the descending trunk is an efficacious approach. It also reduces the difficulty of reconstruction the aRSA in aortic dissection patients.

References

Ameli-Renani S, Pavlidis V, Morgan RA. 2020. Secondary Endoleak Management Following TEVAR and EVAR. Cardiovasc Intervent Radiol. 43(12): p. 1839-1854.

Benhammamia M, et al. 2019. Endovascular And Surgical Management Of Subclavian Artery Occlusive Disease: Early And Long Term Outcomes. Annals of Vascular Surgery. 66.

Boening A, et al. 1999. Two-stage repair of a combined aneurysm of the descending aorta and the aberrant right subclavian artery. Eur J Cardiothorac Surg. 16(2): p. 246-8.

Charalambous S, et al. 2021. Discrimination of High-Risk Type-2 Endoleak after Endovascular Aneurysm Repair through CT Perfusion: A Feasibility Study. J Vasc Interv Radiol. 32(6): p. 807-812.

Clouse WD, et al. Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture.

Ding H, et al. 2018. Outcomes of hybrid procedure for type B aortic dissection with an aberrant right subclavian artery. J Vasc Surg. 67(3): p. 704-711.

Dumfarth J, et al. 2015. Atypical aortic arch branching variants: A novel marker for thoracic aortic disease. J Thorac Cardiovasc Surg. 149(6): p. 1586-92.

Esposito C and Romeo C. 1999. Surgical anatomy of the mediastinum. Semin Pediatr Surg. 8(2): p. 50-3.

Frederick, et al. 1975. Management of Acute Aortic Dissection. Annals of Thoracic Surgery.

Frequency and imaging findings of variations in human aortic arch anatomy based on multidetector computed tomography data. 2013. Clinical Imaging. 37(6): p. 1011-1019.

Kang Z, Shi J, Guo Y. On-table fenestration of frozen elephant trunk graft to achieve aberrant subclavian artery perfusion. ANZ Journal of Surgery.

Khoury SR and Ratchford EV. 2021. Vascular Disease Patient Information Page: Subclavian artery stenosis. Vasc Med. 26(4): p. 464-468.

Kikuchi K, et al. 2005. Surgery for aortic dissection involving an aberrant right subclavian artery. Jpn J Thorac Cardiovasc Surg. 53(12): p. 632-634.

Konstantinou N, et al. 2022. Systematic Review and Meta-Analysis of Outcomes After Operative Treatment of Aberrant Subclavian Artery Pathologies and Suggested Reporting Items. Eur J Vasc Endovasc Surg.

Li JR, et al. 2020. Total arch replacement and frozen elephant trunk for aortic dissection in aberrant right subclavian artery. European Journal of Cardio-Thoracic Surgery.

Li N, et al. 2021. Thoracic Outlet Syndrome: A Narrative Review. J Clin Med. 10(5).

Li T, et al. 2021. Hybrid repair of aberrant right subclavian artery with aortic dissection caused by Kommerell diverticulum. BMC Cardiovasc Disord. 21(1): p. 562.

Ma WG, et al. 2013. Sun's procedure for complex aortic arch repair: Total arch replacement using a tetrafurcate graft with stented elephant trunk implantation. Annals of Cardiothoracic Surgery. 2(5): p. 642-648.

Ma WG, et al. 2013. Sun's procedure of total arch replacement using a tetrafurcated graft with stented elephant trunk implantation: analysis of early outcome in 398 patients with acute type A aortic dissection. Ann Cardiothorac Surg. 2(5): p. 621-8.

Muller M, et al. 2011. Variations of the aortic arch - a study on the most common branching patterns. Acta Radiologica. 52(7): p. 738-742.

Patel RAG and White CJ. 2021. Brachiocephalic and subclavian stenosis: Current concepts for cardiovascular specialists. Prog Cardiovasc Dis. 65: p. 44-48.

Sun LZ, et al. 2013. Sun's procedure for chronic type A aortic dissection: total arch replacement using a tetrafurcate graft with stented elephant trunk implantation. Ann Cardiothorac Surg. 2(5): p. 665-6.

Toole JF and McGraw CP. 1975. The steal syndromes. Annu Rev Med. 26: p. 321-9.

Zhu JM, et al. 2016. Repair of complicated type B dissection with an aberrant right subclavian artery. Interact Cardiovasc Thorac Surg. 22(6): p. 718-22.

Published

2022-07-14

How to Cite

Zhang, J., Kang, Z., Fei, Z., Fan, Y., Guo, Y., & Shi, J. (2022). Intraoperative Fenestration of Frozen Elephant Trunk (FET) and Total Arch Replacement for Aortic Dissection in Aberrant Subclavian Artery. The Heart Surgery Forum, 25(4), E540-E544. https://doi.org/10.1532/hsf.4883

Issue

Section

Articles