ADULT: AORTA: SURGICAL TECHNIQUES

A hybrid aortic re-arching technique

Fuyuki Hirashima, MD,a,b Marek Polomsky, MD,a,b Willie Dong, BS,b Jennifer L. Risi, BS,b and
Chris K. Rokkas, MD,a Burlington, Vt

From the aUniversity of Vermont Medical Center, and bLarner College of Medicine, University of Vermont, Bur-
lington, Vt.
Read at the American Association for Thoracic Surgery Aortic Symposium Workshop, Boston, Massachusetts,
May 13-14, 2022.
Disclosures: The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or re-
viewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article
have no conflicts of interest.
The current affiliation of Dr Rokkas is University of Wisconsin School of Medicine and Public Health, University
of Wisconsin - Madison, Madison, Wis.
Received for publication June 2, 2022; revisions received July 26, 2022; accepted for publication July 29, 2022;
available ahead of print Aug 6, 2022.
Address for reprints: Chris K. Rokkas, MD, University of Vermont Medical Center, H4/344A CSC, 600 Highland Re-arching technique: Bypass grafts to the aortic
Ave, Madison, WI 53792 (E-mail: ckrokkas@yahoo.com). arch branches.
JTCVS Techniques 2022;15:18-21
2666-2507
CENTRAL MESSAGE
Copyright Ó 2022 The Author(s). Published by Elsevier Inc. on behalf of The American Association for Thoracic
Surgery. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- The re-arching technique in-
nc-nd/4.0/).
https://doi.org/10.1016/j.xjtc.2022.07.021 cludes a first stage of construct-
ing bypass grafts to the arch
Hybrid repair of aortic arch aneurysms involves technically branches by utilizing bilateral
challenging de-branching procedures requiring construc-
tion of graft anastomoses to the left subclavian and innom- axillary artery cut-downs, and a
inate arteries. Exposure of the intrathoracic segment of the second stage of endovascular
aortic arch branches may be difficult, particularly that of the completion.
left subclavian artery, frequently requiring a left carotid to
subclavian artery bypass before the de-branching proced-
ure.1 We present a simplified method of aortic arch revascu-
larization, termed re-arching, where the bypass grafts are
tunneled from the ascending aorta to the axillary arteries
compression and crowding of the graft. The 8-mm graft off the ascending
bilaterally. A subsequent thoracic endovascular aortic repair aorta was anastomosed to the proximal left common carotid artery in an
(TEVAR) of the aortic arch aneurysm is performed. This end-to-side fashion (anastomosis A), and the origin of the left common ca-
method precludes the need for a carotid to subclavian artery rotid artery was ligated. The patient was then weaned off CPB. Next, the
bypass before TEVAR. 10-mm branch off the ascending aorta was tunneled to the left infraclavic-
ular space through the second intercostal space, and it was anastomosed to
the left axillary artery in an end-to-side fashion (anastomosis B). The sec-
METHODS ond intercostal space is mostly a fixed area not prone to kinking. Tunneling
The patient reported on herein provided informed written consent for is performed with a long curved blunt clamp in a direction from the left in-
the publication of study data. As an individual case report with no identifi- fraclavicular area towards the anterior mediastinum under direct visualiza-
able patient information, our institutional review board deemed publication tion. An adequate opening is created within the intercostal space to provide
of the study exempt from approval. comfortable passage of the graft. The 10-mm graft to the right axillary ar-
A 58 year-old woman presented with an asymptomatic aneurysm of the tery that had been previously used as an arterial inflow conduit was
distal aortic arch associated with a penetrating atherosclerotic ulcer tunneled into the mediastinum through the right second intercostal space.
(Figure 1). Due to multiple comorbidities and extensive atherosclerosis Tunneling is performed in a direction from the posterior chest wall to the
of the aortic arch, she would have been a high-risk patient for an open right infraclavicular area. The graft was then anastomosed to the 10-mm
anatomic reconstruction under circulatory arrest. Bilateral axillary artery graft supplying the left axillary artery in an end-to-side configuration (anas-
cut-downs were performed. A 10-mm graft was anastomosed to the right tomosis C). The innominate artery was ligated at its origin. The patient
axillary artery, following administration of 3000 U heparin intravenously. returned 4 weeks later to undergo a TEVAR procedure with a
A median sternotomy was then performed and cardiopulmonary bypass 32 3 28 3 178-mm endograft deployed to zone 0. Angiography showed
(CPB) was instituted via the right axillary artery and right atrium with no type 2 endoleak, therefore endovascular occlusion (plug) of the left sub-
the patient being fully heparinized. A multibranch aortic arch graft was clavian was not required (Figure 3).
used (Plexus; Terumo Aortic), and a patch including the origins of the
10-mm and 8-mm grafts was tailored from this graft (Figure 2 and
Figure E1). This patch was anastomosed to the anterolateral aspect of the RESULTS
ascending aorta during a short period of cardioplegic arrest. It is important Bilateral radial arterial monitoring showed equal and
to avoid anastomosis to the anterior wall of the ascending aorta to prevent appropriate systemic blood pressures. Follow-up computed

18 JTCVS Techniques c October 2022

 Adult: Aorta: Surgical Techniques

FIGURE 1. Aneurysm of the distal aortic arch associated with a penetrating atherosclerotic ulcer (arrows).

tomography angiogram showed no evidence of endoleak; a patient’s aorta. We believed that the application of a partial
completely thrombosed aneurysm sac; and patent grafts occlusion clamp on the ascending aorta would not have
supplying the right axillary, left axillary, and left common been entirely safe. In other de-branching cases, we have per-
carotid arteries (Figure 3). formed the aortic anastomosis without the use of CPB.5 For
the proximal aortic anastomoses, a bifurcating graft or even
2 separate grafts can be used. By using the multibranch
DISCUSSION
graft, the branches are optimally oriented without protrud-
We believe that low-risk patients who require extensive
ing through the side of the aorta. The remaining graft mate-
replacement of the aortic arch should still have an anatomic
rial is also used in the reconstruction.
repair. However, a hybrid approach is preferred to anatomic
reconstruction in high risk patients.2,3 This staged proced-
ure frequently requires the additional step of a left carotid CONCLUSIONS
to subclavian artery bypass or a subclavian artery transposi- Our novel hybrid re-arching approach of aortic arch recon-
tion to revascularize the hard-to-reach left subclavian ar- struction simplifies the standard de-branching technique by
tery.4 This is often necessary even when the de-branching avoiding the technically challenging intrathoracic anastomo-
operation is performed on CPB. ses to the innominate and the left subclavian arteries. In addi-
For our patient, we used CPB and a brief period of cardi- tion, the anastomosis to the left axillary artery eliminates any
oplegic arrest to safely perform the anastomosis of the patch
graft island to the aorta, given the relatively small size of the

FIGURE 2. The re-arching technique: Bypass grafts to the aortic arch

branches. A: Aorta to left common carotid artery bypass. B: Aorta to left FIGURE 3. Completion angiography following deployment of endovas-
axillary artery bypass. C: Interposition bypass graft to the right axillary cular graft to zone 0 shows opacification of the aortic arch branches and
artery. obliteration of the aneurysm.

JTCVS Techniques c Volume 15, Number C 19

Adult: Aorta: Surgical Techniques

need for a left carotid to left subclavian artery bypass or sub- and other arch diseases. J Thorac Cardiovasc Surg. 2012;144:1286-300.
1300.e1-2.
clavian artery interposition before TEVAR, thus simplifying 3. Milewski RK, Szeto WY, Pochettino A, Moser GW, Moeller P, Bavaria JE. Have
the staging of the hybrid procedure. Use of the technique in hybrid procedures replaced open aortic arch reconstruction in high-risk patients?
selected high-risk patients may be indicated. A comparative study of elective open arch debranching with endovascular stent
graft placement and conventional elective open total and distal aortic arch recon-
struction. J Thorac Cardiovasc Surg. 2010;140:590-7.
References 4. Canaud L, Ziza V, Ozdemir BA, Berthet JP, Marty-Ane CH, Alric P. Oucomes of
1. Hage A, Ginty O, Power A, Dubois L, Dagenais F, Appoo JJ, et al. Management of left subclavian artery transposition for hybrid aortic arch debranching. Ann Vasc
the difficult left subclavian artery during aortic arch repair. Ann Cardiothorac Surg. 2017;40:94-7.
Surg. 2018;7:414-21. 5. Kollias VD, Lozos V, Angouras D, Toumpoulis I, Rokkas CK. Single-stage, off-
2. Cao P, De Rango P, Czerny M, Evangelista A, Fattori R, Nienaber C, et al. System- pump hybrid repair of extensive aneurysms of the aortic arch and the descending
atic review of clinical outcomes in hybrid procedures for aortic arch dissections thoracic aorta. Hellenic J Cardiol. 2014;55:355-60.

20 JTCVS Techniques c October 2022

 Adult: Aorta: Surgical Techniques

FIGURE E1. Intraoperative view following completion of bypass

grafts. A: Aorta to left common carotid artery bypass. B: Aorta to left axil-
lary artery bypass. C: Interposition bypass graft to the right axillary artery.

JTCVS Techniques c Volume 15, Number C 21