We replaced ascending aorta in TAAD patients without arch involvement and used self modified standard graft to preserve native arch branch, ensuring a successful procedures and rapid recovery. This procedure reduce the surgical steps of the traditional approach. It's easy to perform and avoid deep hypothermic circulatory arrest, reducing postoperative complications.
The aortic arch greater curvature was buried, allowing a less invasive approach to avoid circulatory arrest while preserving native branches. Custom modification in situ were required due to the left subclavian arteries, proximity to the bridge, ensuring branch perfusion. The aorta was measured at key points, including the ascending aorta, the aortic arch, and the descending thoracic aorta.
After selecting the appropriate artificial vascular graft, evaluating the aortic structures and administering heparin, extra corporeal circulation was established through the axillary and femoral arteries. Extra corporeal circulation was assisted to safely perform the surgical intervention. The ascending aorta was excised and a tailored artificial graft selected based on preoperative computed tomography angiography measurements, was sutured to replace the diseased aortic segment.
Concurrently, the aortic valve was replaced with a mechanical valve prosthesis to ensure a long-term hemodynamic stability. After replacing the ascending aorta, the chest was left open to facilitate subsequent evaluation of the distal anastomosis. Kelly clamps or titanium clips were placed at the location of the distal anastomosis to serve as clear anatomical reference points for imaging and subsequent surgical interventions.
Digital subtraction angiography was performed to assess the integrity and patency of the newly constructed aortic segment, and then the position and length of the stent graft openings were determined. To avoid endo leak and incomplete lesion management, inside two windowing was planned for the left subclavian artery to implant the VIABAHN and in vitro fenestration was performed for the remaining two arch branches. The anterior end of the stent was covered and extended beyond the distal aortic anastomosis by 10 to 15 millimeters.
The length of the stent graft window was defined using the proximal end of the brachiocephalic trunk osteum and the distal end of the left common carotid artery osteum. Fixed sutures made of radiopaque materials such as stainless steel wire or thin metal plates were used to position the window of the stent grafts with the corresponding branches of the aortic arch. Using interrupted or continuous sutures, the metal wire or sheet was carefully secured to the stent graft at the edges of the window.
Stable positioning and precise alignment with the arch vessels, particularly at the level of the brachiocephalic trunk and left common carotid artery were ensured to minimize the risk of restenosis or misalignment. After implanting the modified stent grafts through the femoral artery, the handle was rotated and the stent graft was released before slowly unsheathing it. The bracket was open to the starting position of the bracket overlay.
The opening side of the stent graft was identified by confirming the marker corresponding to the white dot on the handle. The anterior and posterior positions of the opening window were marked using the corresponding stent graft segments. The position of the aortic arch and its branches was determined by marking the aortic arch and two branches with screen markers and corresponding bone markers.
A guide wire was advanced through the sheath into the left subclavian artery under real-time fluoroscopy to ensure accurate catheter placement. A balloon catheter was introduced through the sheath and advanced to the osteum of the subclavian artery. Balloon dilatation was gradually performed at the site of the stent grafts to optimize stent expansion and restore blood flow in the dissected aorta.
A VIABAHN uncovered stent graft was deployed across the site to minimize the risk of endoleak and secure the position of the stent grafts. A second stent was implanted in the descending aorta to eliminate as much of the false lumen as possible. Digital subtraction angiography was performed to assess the outcome of the hybrid repair.
High resolution imaging of the entire aorta was obtained. After confirming the absence of leakage and successful stent graft placement, the chest was closed in layers by suturing the pericardium, re-approximating the chest wall muscles and fascia, and closing the skin while ensuring proper hemostasis to minimize postoperative complications. Postoperative computed tomography angiography imaging confirmed no significant contrast leakage, no stent dislodgement, and smooth blood flow in all three branches of the aortic arch indicating successful stent placement and stability.
