Aortic Arch Debranching: The Off-Pump Technique
This video demonstrates aortic arch debranching without the usage of cardiopulmonary bypass.
In this case, the debranching was performed on a sixty-one-year-old male smoker who was diagnosed with type B aortic dissection three months prior, and presented to the emergency department with chest pain and an enlarging thoracic dissecting aneurysm.
Computed tomographic angiography confirmed that the proximal descending thoracic aorta now measured 4.7 cm whereas it measured 3.3 cm a few months prior. The extent of the dissection remained the same, starting just distal to the left subclavian artery and extending to the aortic bifurcation.
One concern was the proximal extent of the dissection, which originated within a few millimeters of the left subclavian artery. Intraoperative findings confirmed the imaging by showing the dissected aorta at the base of the left subclavian artery.
Surgeons performed a two-stage operation. First, with the aorta to innominate and aorta to left carotid bypass via usage of a 10 mm graft constructed into a Y configuration.
First, surgeons constructed the bypass conduit with one 10 mm graft, cut in half, then anastomosed in a Y configuration with the proximal end beveled.
A side biting clamp was applied to the ascending aorta and a 2 cm aortotomy was created. The proximal anastomosis was then constructed with a 4-0 Prolene suture.
Attention was then turned to the left carotid artery, which was clamped distally. 3-0 pledgetted Prolene sutures were placed on the aortic arch millimeters below the carotid ostium and the base of the carotid was transected.
One limb of the graft was then anastomosed to the left carotid artery in an end-to-end fashion using a 5-0 Prolene suture. The graft was then deaired, clamps removed, and the flow returned to the left carotid artery.
Next, attention was turned to the innominate artery. Again, 3-0 pledgetted Prolene sutures were placed on the aortic arch millimeters below the innominate artery ostium. They were tied and the vessel was transected. The other limb of the graft was anastomosed to the innominate artery in a similar fashion with a 5-0 Prolene suture.
The graft was deaired, clamps removed, and the flow returned to the innominate artery. Adequate hemostasis was confirmed at the aortic arch.
Lastly, a radio opaque marker was placed at the proximal anastomosis for later easy visualization with fluoroscopy.
Postoperatively, the patient did well and computed tomographic angiography confirmed adequate graft lie and flow. He then underwent the second stage of the operation with a left carotid to subclavian bypass and thoracic endovascular aortic repair with two 32 mm x 109 mm grafts.
The patient’s remaining course was uneventful, and he was discharged home two days after the second operation.
In performing aortic arch debranching, surgeons must consider whether to perform the procedure with two or three head vessels. This decision is determined by the location and technical difficulty of the left subclavian artery, as well as its association with the thoracic aortic dissection.
Another technical consideration is the anastomotic steps. The first step is the aortic anastomosis, which ensures that blood flow can resume to the head vessels as soon as possible. Afterwards, it is technically less difficult to perform the distal anastomoses starting from left to right, as is usually the case in standard aortic arch replacement. Always be sure to deair and immediately resume blood flow to the completed arch vessel.
One helpful trick for later TEVAR placement is to place a radio opaque marker on the ascending aortic anastomosis. This improves visualization during later usage of fluoroscopy.
- Ghazy, Tamer, et al. "Off-pump debranching and thoracic endovascular aortic repair for aortic arch pathology." Innovations 10.3 (2015): 163-169.