Surgical Science, 2011, 2, 335-337
doi:10.4236/ss.2011.26071 Published Online August 2011 (
Copyright © 2011 SciRes. SS
Hybrid Aortic Arch Replacement: A Novel Surgical
Technique for a Difficult Problem
Ravi de Silva1*, Simon Messer1, Vimal Raj2, Stephen Large1
1Department of Cardiothoracic Surgery, Papworth Hospital, Cambridgeshire, UK
2Departme nt of Radiolog y, Papworth Hospital, Cambridgeshire, UK
Received April 13, 2011; revised June 4, 2011; accepted June 10, 2011
Aneurysms of the aortic arch and descending aorta are invariably fatal if left to expand, but also represent
considerable surgical challenges. The development of endovascular stent grafts in combination with aortic
debranching has produced results at least comparable to the more traditional surgical approach, but with con-
siderably less co-morbidity. We describe a technique for debranching of the aortic arch without the use of
circulatory support, and in doing so creating a landing zone for thoracic endovascular aneurysm repair (TE-
VAR). Although this procedure has been described, innovative features of our technique include transection
of the left hemisternum to produce excellent surgical exposure, and ligation of the debranched arch vessels to
prevent Type II endoleaks following TEVAR. Additionally, by not using mechanical circulatory support, we
remove the associated pathophysiological insult, inflammatory response, and coagulopathy that is synony-
mous with cardiopulmonary bypass. There is also no need for circulatory arrest, with its associated perils.
Keywords: Aortic Arch, Endovascular Procedures/Stents, Off Pump Surgery
1. Introduction
Arch and descending aortic aneurysms are complex
problems which have traditionally been treated with ex-
tensive surgical procedures needing circulatory support,
and often a period of circulatory arrest [1,2]. The associ-
ated techniques of cerebral protection including ante-
grade or retrograde selective cerebral perfusion and deep
hypothermia have all been showed to produce good sur-
gical outcomes, but with little information on the cogni-
tive outcome which is of great concern to patient and
surgeon alike [3]. The use of endovascular stents and
TEVAR is suitable in some descending aortic aneurysms
[4], but in other cases and for arch aneurysms, there is no
satisfactory landing zone to anchor the stent, without
jeopardizing one or more of the arch vessels. On occa-
sion this problem can be negotiated by landing the stent
between left common carotid and left subclavian arteries.
Inflow to the left subclavian artery is restored by a con-
duit from the left common carotid artery. Hybrid (open
surgery followed by TEVAR) approaches to arch aneu-
rysms are well reported. This is described via a median
sternotomy with and with out the use of cardiopulmonary
bypass [5]. The arch vessels are debranched and then
simply stented across. We have highlighted three main
shortcomings of this approach. Firstly surgical exposure
via a median sternotomy alone can be very limited for
distal arch vessels, making the left common carotid and
left subclavian anastamoses extremely difficult. Sec-
ondly, by leaving the debranched native arch vessels
intact, there is a risk of Type II endoleak following TE-
VAR [6,7], with retrograde flow back into the arch an-
eurysm. Thirdly, cardiopulmonary bypass and its associ-
ated inflammatory, coagulopathic and pathophysiological
sequelae, is a very unattractive adjunct to this type of
surgery and we advocate doing this procedure off pump.
Our technique utilizes a modified sternotomy for better
access and ligation of individual native arch vessels to
prevent future endoleaks, without mechanical circulatory
2. Case Report
A 69 year old ex-smoker presented with an 18 month
history of dysphonia. He had been involved in a serious
car accident 35 years previously, had poorly controlled
hypertension, and had undergone total thyroidectomy for
carcinoma 20 years ago. Investigations revealed left vo-
cal cord palsy, and contrast enhanced computerised to-
mography confirmed an 8.7 cm aneurysm of the distal
aortic arch (Figure 1). A multidisciplinary team 2-stage
approach was employed. Stage one involved surgical
debranching of the aortic arch, in preparation for stage
two—thoracic endovascular aneurysm repair (TEVAR).
Prior to surgery the patient was anaesthetised and in-
tubated with a single lumen endotracheal tube. Suitable
peripheral and central venous access was gained for in-
fusions and monitoring of central venous pressure. Bilat-
eral radial and a single femoral artery lines were sited.
Following median sternotomy the ascending aorta was
slung with a tape which was retracted caudally to bring
the aortic arch more into view. The arch branches were
then dissected out. The left subclavian artery was the
first to be debranched. Access to it is invariably ex-
tremely difficult, but in this case was improved by divi-
sion of the left hemisternum at the level of the first in-
tercostal space. This incision is furth er extended to create
a high anterior mini-thoracotomy, sacrificing of the left
internal thoracic artery (LITA) in doing so. This lateral
displacement of the manubrium allows for better visu-
alisation of the first part of the subclavian artery. Ten
thousand units of heparin was administered and the left
subclavian artery cross clamped proximally and distally.
Figure 1. 3-D CT reconstruction of the ascending, arch and
descending aorta, showing the aneurysm (A), which arises
just after the aortic arch (AA) branches. The anatomy of
the arch and the proximity of the aneurysm to the arch
vessels precludes TEVAR without aortic Debranching.
An 8 mm vascular graft was anastamosed end-to-side to
the left subclavian, after which the clamps were released
and the graft de-aired.
Attention was then turned to the ascending aorta to
which a side-biting clamp was applied. A 1 cm trans-
verse aortotomy was made to which the mid-point of
another 8 mm vascular graft was anastamosed in a side-
to-side fashion. The graft lay perpendicular to the as-
cending aorta, in the line of the transverse aortotomy.
The side-biting clamp was removed and the graft de-
aired. The two limbs of this graft were then used to
debranch the remaining arch vessels, with the right limb
anastamosed to the innominate artery, and the left limb
to the left common carotid artery, in an end-to -side fash-
ion. The proximal end of the graft to the left subclavian
artery was then anastamosed end-to-side to the left ca-
rotid graft. Finally the arch vessels were ligated p roximal
to their anastamoses with the vascular grafts, protamine
administered, haemostasis secured, and the chest closed.
Particular attention is given to stabilising the left hemis-
ternum with additional sternal wires which apposed the
transected portions of the hemisternum. A post-proce-
dure CT reconstruction is shown in Figure 2. The patient
was discharged on the fourth post-operative day to await
3. Conclusions
Advances in endovascular technology have revolution-
ized the role of surgeo ns in major aortic diseases such as
Stamford Type B dissections, aneurysms, and transec-
tions. The ascending and arch aorta however, remains an
area of difficulty, as sacrificing inflow to the arch
branches by stent placement, can be catastrophic. A hy-
brid technique for arch debranching has previously been
described [5], but we have modified this approach to
address its deficiencies. Specifically these shortcomings
are surgical exposure, the potential for endoleaks fol-
lowing TEVAR, and the need for cardiopulmonary by-
Exposure of a surgical site is key to a successful pro-
cedure, and we have improved access to the distal arch
vessels by transection of the left hemisternum in the first
intercostal space. This approach on the right hemister-
num has previously been described for access to the right
subclavian artery [8], and in our technique we find it
gives excellent exposure of the left common carotid and
left subclavian arteries.
Endoleak following TEVAR is well recognised [6,7],
and type II endoleaks following arch debranching can be
particularly difficult to correct, and will eventually lead
to aneurysm rupture. We proximally ligate the debran-
ched native arch vessels to prev ent retrograde inflow into
Copyright © 2011 SciRes. SS
Copyright © 2011 SciRes. SS
Figure 2. 3-D CT reconstruction of the ascending, arch and
descending aorta, showing the aneurysm (A), and the 3
conduits anastamosed to the branc hes of the aortic arch (I =
innominate artery conduit, C = left common carotid artery
conduit, S = left subclavian artery c o nduit).
the aneurysm, which eliminates the risk of type II en-
doleaks in this area. Although ligating normal arteries
would seem counterintuitive, if left patent the backflow
following TEVAR will eventually leave the patient at th e
risk of aneurysm rupture, negating any prognostic benefit
of intervention.
Our technique does not need circulatory support with
its possible complications. Despite the many advantages
of cardiopulmonary bypass, it can also cause significant
morbidity, especially the associated inflammatory re-
sponse and coagulopathy. By addressing the arch vessels
sequentially, ligating the vessels only after completion of
the debranching, and careful haemodynamic manage-
ment by the anaesthesiologist, we have managed to do
this procedure without the help of cardiopulmonary by-
pass. This makes the concept of hybrid surgery even
more attractive than the open surgical alternative, which
also requires a period of hypothermic circulatory arrest.
Overall, our modified technique of hybrid aortic
debranching allows the surgeon to perform the procedure
with relative ease, so that the patient may have an expe-
ditious recovery and proceed to TEVAR.
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