Aortic arch exclusion for extended thoracic aortic aneurysms and dissections

Objectives: To evaluate a hybrid treatment of atheromatous anddissecting thoracic aortic aneurysms (TAA) involving the aorticarch in high risk patients (HRP), excluded from conventional aorticarch surgery.Methods: Between May 1999 and April 2004, we treated 49 HRP,of which 7 females, for TAA with industrial endoluminal stentgrafts.Mean age was 69+/-9 years old. Among them, and due to aspecial recruitment, 14 patients (28.6%) were admitted for endovascularexclusion of the aortic arch. Seven of them presented withthoracic aortic aneurysm, and 7 had a thoracic aortic dissection.Supra-aortic vessels were first transposed surgically. We performed7 total arch transpositions (transposition of all great vessels, donethrough median sternotomy and bypass to the ascending aorta), and7 hemi-arch transpositions (transposition of the left common carotidand sub-clavian arteries by cervicotomy). Secondly, we excludedthe diseased aortic arch endovascularly. We used Talent® endograftsin 8 patients, Excluder® in 3 and Zenith® in 3.Results: Amongst these 14 patients, 1 died 2 days after endograftingfrom multi-organ failure after iliac rupture during endoluminalaccess. After hemi or total arch transposition, 1 patient presented aminor stroke. The endovascular step led to 2 strokes, including theworsening of the post-surgical minor stroke, leading to a postoperativestroke/death rate of 21.4%. The delayed occlusion of aleft common carotid bypass at its origin caused a minor stroke. Weobserved 2 types: 1 residual endoleaks (14.3%) of which onethrombosed spontaneously; the other is under surveillance.During a mean follow-up of 13.6+/-5.8 months (1-35 months), 1patient (7.1%) died from worsened respiratory failure at 3 months.The late aneurysm exclusion rate was 100%, and the late rate ofdissections thoracic false channel thrombosis was 87,5%. We observedno complication related to the endografts, especially no caseof aorto-esophageal fistula.Conclusions: Preliminary transposition of supra-aortic vesselsallows the endovascular exclusion of the aortic arch in HRP, thusoffering the advantages of a lighter treatment. Aortic endograftingafter surgical transposition proved to be feasible and to offer goodmid-term results, although long-term surveillance is needed. Specializedsurgical centers with both endovascular & surgical expertiseoffer the best management possibilities for these patients.