Hybrid thoracic endovascular aortic repair via right anterior minithoracotomy

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1 Hybrid thoracic endovascular aortic repair via right anterior minithoracotomy Javier E. Anaya-Ayala, MD, a,b Zulfiqar F. Cheema, MD, PhD, a Mark G. Davies, MD, PhD, MBA, a,b Jean Bismuth, MD, a,b Basel Ramlawi, MD, a,b Alan B. Lumsden, MD, a,b and Michael J. Reardon, MD a,b Objective: Hybrid thoracic endovascular aortic repair (TEVAR) has expanded the surgical management of complex thoracic aneurysms. Aortic arch debranching generally requires a sternotomy. We describe our experience performing a right anterior minithoracotomy for hybrid TEVAR. Method: During a 3-year period, 7 patients (aged years; 57% were male) with aortic arch aneurysms underwent hybrid TEVAR via a right anterior minithoracotomy. Of all with prior thoracic or abdominal aortic surgery, 4 had a prior sternotomy. All patients included in this series had an American Society of Anesthesiology score of 4 or greater. Results: Repairs were performed via a 5-cm incision at the third to fourth intercostal space to access the ascending arch. A Satinsky clamp on the ascending aorta facilitated bypass with the 10-mm arm of a bifurcated 10/12- mm graft to the innominate artery or right common carotid artery (12-mm arm: endoprosthesis conduit). The remaining arch vessels were bypassed as needed; subsequently, a thoracic stent graft was deployed by the 12- or 14-mm arm. Primary technical success was 86% (6 patients); 1 patient required conversion to sternotomy secondary to bleeding. Complications included cerebrovascular accident in 2 patients (28%) and respiratory failure in 2 patients (28%). The average length of stay was 12 days with no wound infection. One death occurred during the 30-day period. Conclusions: Right anterior minithoracotomy is a compelling, less invasive technique for hybrid TEVAR. Further experience will be necessary to completely evaluate the merits of this approach. (J Thorac Cardiovasc Surg 2011;142:314-8) With the advent and development of minimally invasive techniques, more thoracic and thoracoabdominal aortic aneurysms are being treated with thoracic endovascular aortic repair (TEVAR) to decrease the morbidity and mortality associated with open surgery. In the case of endovascular abdominal aortic aneurysm repair (EVAR), recent data from the United Kingdom EVAR trial investigators 1 concluded that EVAR provides early benefit with respect to aneurysm-related mortality; however, no differences have been seen in total mortality or aneurysm-related complications in the long term. EVAR in their study was more costly and associated with increased rates of graft-related complications and reinterventions. One of the limitations of TEVAR are inadequate landing zones for aneurysms that From the Department of Cardiovascular Surgery, a Methodist DeBakey Heart & Vascular Center, and The Methodist Hospital Research Institute, b The Methodist Hospital, Houston, Tex. Disclosures: The authors have nothing to disclose with regard to commercial support. Presented at the Aortic Symposium 2010, April 29 30, 2010, New York, New York, as part of the presentation on demand portion of the meeting. Received for publication July 5, 2010; revisions received Sept 7, 2010; accepted for publication Oct 16, 2010; available ahead of print Jan 31, Address for reprints: Michael J. Reardon, MD, Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, The Methodist Hospital, 6550 Fannin Street, Suite 1401, Houston, TX ( MJReardon@tmhs. org) /$36.00 Copyright Ó 2011 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery doi: /j.jtcvs involve the aortic arch, which would occlude the brachiocephalic vessel or carotid arteries and make them unsuitable for endovascular treatment. 2 An alternative approach for treating complex aortic arch thoracic pathology is the hybrid TEVAR, which combines aortic arch vessel debranching with concomitant antegrade endovascular stent graft in a 1-stage procedure. 3-5 The principal advantage of the hybrid procedure is to eliminate the need for aortic clamping and its consequence of increased morbidity and mortality. The avoidance of aortic crossclamping decreases the risk of ischemic complications. 6 Even when using the hybrid TEVAR, a midline sternotomy is usually required in the debranching of the great vessels of the aorta. 5 Despite the initial decreased 30-day morbidity and mortality associated with the hybrid procedure compared with the open procedure, the midline sternotomy necessary to perform the debranching introduces its own risks. The rate of mediastinitis after any procedure involving a midline sternotomy is 1% to 4%. 7 In an effort to avoid sternotomies, especially in high-risk patients and those with prior cardiac surgery, we developed the right anterior minithoracotomy (RAM) approach, which was previously described by our group. 8 The use of RAM for other cardiac procedures (eg, mitral valve repair) has demonstrated that direct visualization with a transthoracic clamp technique is reproducible with low mortality and morbidity rates, with results comparable to midterm outcomes of the 314 The Journal of Thoracic and Cardiovascular Surgery c August 2011

2 Acquired Cardiovascular Disease Abbreviations and Acronyms EVAR ¼ endovascular abdominal aortic aneurysm repair RAM ¼ right anterior minithoracotomy TEVAR ¼ thoracic endovascular aortic repair conventional approaches. 9 This technique will be particularly useful in patients who are not medically stable enough for a midline sternotomy or who have undergone prior cardiac surgery. With the use of RAM, repair of an aortic aneurysm involving the arch can become a truly minimally invasive procedure. We describe our initial experience performing this technique. MATERIALS AND METHODS Patient Selection and Surgical Technique All patients selected for this procedure had a thoracic aortic aneurysm that was evident on computed tomography scans. Indications for intervention were based on the presence of symptoms or the aneurysm size (>6 cm) in the aortic arch extending to a proximal location requiring endograft placement in landing zone 0 with debranching of the supraaortic trunks. These patients had to have a healthy ascending aorta to facilitate branch grafting; however, a prior ascending aortic repair with a Dacron graft was not a contraindication, providing a secure partial clamping in 3 patients. All patients were not suitable for conventional open surgical repair because of severe preoperative comorbidities, low physiologic reserve, or advanced age. All repairs were performed via a 5-cm incision at the third to fourth intercostal space to access the ascending arch. A back table ex vivo 10/12-mm bifurcated Hemashield Dacron graft was created. After partial heparinization, a partial occluding clamp was used on the ascending aorta; the 10-mm arm of the bifurcated 10/12 mm graft was tunneled to the neck and anastomosed to the innominate artery or the right common carotid via a separate neck incision. The remaining arch vessels were bypassed through the right common carotid artery to the left common carotid artery and left carotid-subclavian bypasses with 8-mm Dacron grafts. The innominate and left common carotid arteries were ligated, and the left subclavian artery was coiled at the aortic origin to avoid type 2 endoleaks. An antegrade stenting of the aortic arch was performed through the RAM via the remaining 12- or 14-mm limb of the aortoinnominate or aorto-carotid graft (Figure 1, A, B). We routinely use transcranial Doppler monitoring in all thoracic endografting procedures. RESULTS Seven patients (aged years; 57% were male) with thoracic aortic aneurysms underwent hybrid TEVARs via RAM, all with prior thoracic or abdominal aortic surgery and coronary artery disease. These patients had an American Society of Anesthesiology score of 4 or greater. Primary technical success was 86% (6/7 patients); 1 patient required conversion to sternotomy secondary to uncontrollable bleeding. Complications included cerebrovascular accident in 2 patients (28%) and respiratory failure in 2 patients (28%). The average length of stay was 12 days with no wound infection. One death occurred during the 30-day mortality (14%). The rest of the patients recovered without major complications. Table 1 summarizes the patient demographics and clinical features. DISCUSSION Although comparisons of endovascular versus open thoracic aortic aneurysm repair with a 5-year follow-up have validated the role of TEVAR, 10 endovascular treatment has specific anatomic limitations. Proximal landing zone anatomy can be overcome by debranching the aortic arch to accomplish a hybrid aortic repair. Milewski and colleagues 4 recently reported a retrospective comparative analysis of hybrid arch procedures versus open reconstructions. They suggested that the hybrid approach has a lower mortality for high-risk patients aged more than 75 years. This extends the indication for a hybrid approach in patients previously considered prohibited for conventional open arch repair. This article presents our early experience with a viable alternative to midline sternotomy for access to the aortic arch vessels: RAM. This was a select group of patients. Our criteria were based on comorbidities, smoking history, advanced age, need for supraaortic trunk debranching, as well as quality of the ascending aorta and adequate proximal landing zones for stent-graft deployment (Figure 2, A, B). RAM facilitates the treatment of patients in whom a sternotomy is contraindicated, such as high-risk patients and patients with prior mediastinal radiation, prior sternal wound infection, previous bypass grafts at risk, and mediastinal structures adherent to the posterior sternum, especially with the presence of large aneurysms. 11,12 In this series, 4 patients had a previous sternotomy for prior coronary artery revascularization (1 patient) and 3 patients had ascending aorta replacement. Although the ascending aorta was more difficult to expose in these patients, the ascending aorta grafts provided secure clamping in our 3 cases. An algorithm to assist in decision-making is shown in Figure 3. The possible benefits of RAM include decreased postoperative pain, maintenance of sternal stability with decreased infection, decreased length of stay, decreased postoperative pulmonary complications, fewer transfusions, and improved cosmetic results. Although RAM provides adequate exposure to visualize and control the ascending aorta and proximal aortic branches, it remains inferior to sternotomy in overall exposure of the heart and major vascular structures. This was demonstrated in the patient who died, in whom uncontrolled bleeding required emergency sternotomy for intraoperative control. Although anterior thoracotomy is thought to be less invasive than a median sternotomy, the incidence of wound complications, such as incisional hernia, dehiscence, seroma formation, and infection, with an anterior thoracotomy incision for minimally invasive direct coronary artery bypass has been reported to be significant by Ng et al 13 (9% vs 1% with median sternotomy). Previous right thoracotomy and severe pulmonary disease and The Journal of Thoracic and Cardiovascular Surgery c Volume 142, Number 2 315

3 FIGURE 1. A, Schematic drawing of the procedure. A 5-cm incision at the third intercostal space to access the ascending arch. A partial occluding clamp is used on the ascending aorta to attach the 10-mm arm of the bifurcated 10/12-mm graft to the right common carotid artery (RCCA). The remaining arch vessels are bypassed through the RCCA-left common carotid artery (LCCA) and left subclavian artery bypass graft (BPG). Antegrade stenting of the aortic arch is carried out through the RAM via the remaining 12-mm limb. B, Intraoperative angiogram in a patient with prior sternotomy showing the ascending aorta to RCCA BPG (black arrow), RCCA-LCCA BPG (white arrow), and stent graft deployment via a 12-mm limb (hollow arrow) through the anterior minithoracotomy and complete exclusion of the aneurysmal sac. LSA, Left subclavian artery; Asc Ao, ascending aorta. TABLE 1. Patients demographics and clinical aspects Patient No. Age/sex Medical and surgical history 1 91 y/m CAD, s/p PCI, HTN BPH, s/p AAA repair 2 81 y/m HTN, CAD, CVA, CKD, s/p CABG 3 66 y/m CAD, HTN, TIA type A aortic dissection, s/p replacement 4 70 y/f DM2, COPD, CAD, ascending aortic aneurysm s/p replacement 5 83 y/f HTN, COPD, PAD, s/p aorto-bifemoral BPG 6 65 y/f HTN, CAD, CKD, s/p TAAA repair 7 81 y/m CAD, HTN, ascending aortic aneurysm s/p replacement Clinical presentation TAA size TAA 6.2-cm, a TAA 9 cm, TAA 5.9 cm, TAA 8 cm, TAA 6.1 cm Symptomatic TAA 6 cm,, contained rupture TAA 6.3 cm, a Prior sternotomy Case urgency Bypass No Elective Ascending aorta-rcca, Yes Urgent Ascending aorta-innominate Yes Urgent Ascending aorta-innominate Yes Urgent Ascending aorta-rcca, No Urgent Ascending aorta-innominate No Emergency Ascending aorta-rcca, Yes Elective Ascending aorta-rcca, Early/late complication Postoperative DVT, full Respiratory failure CVA Type I endoleak, stent-graft extension Bleeding required sternotomy, respiratory failure, pneumonia, CVA, death TAA, Thoracic aortic aneurysm; CCA, common carotid artery; LSA, left subclavian artery; RCCA, right common carotid artery; LCCA, left common carotid artery; CAD, coronary artery disease; HTN, hypertension; CVA, cerebrovascular accident; COPD, chronic obstructive pulmonary disorder; PAD, pulmonary artery disease; DM2, diabetes mellitus type 2; TIA, transient ischemic attack; CKD, chronic kidney disease; CABG, coronary artery bypass graft; PCI, percutaneous coronary intervention; AAA, abdominal aortic aneurysm; BPH, benign prostatic hyperplasia; BPG, bypass graft. 316 The Journal of Thoracic and Cardiovascular Surgery c August 2011

4 Acquired Cardiovascular Disease FIGURE 2. A, Computed tomography angiogram. Three-dimensional reconstruction showing a 6.2-cm aortic arch aneurysm in a 91-year-old man with high risk for open repair. The aneurysm involves the left subclavian artery near the LCCA and innominate and the ascending aorta provides adequate landing zone for stent-graft deployment and debranching. B, Intraoperative completion angiogram showing the ascending aorta to RCCA BPG (black arrow), RCCA-LCCA BPG (white arrow), and stent graft deployment via a 12-mm limb (hollow arrow) through the anterior minithoracotomy and complete exclusion of the aneurysmal sac. pulmonary hypertension may preclude RAM approaches in the minority of patients requiring single-lung ventilation to inspect suture lines. The pericardium is less effectively inspected and drained during surgery, and drainage may be impaired in the postoperative period, increasing the risk of subacute tamponade in the presence of excess postoperative mediastinal drainage, although this did not occur in our experience. We expect that continued use of RAM for thoracic aortic debranching in appropriately selected patients will lead to further decreased morbidity. However, the costeffectiveness and clinical merit of these advances compared with those of more conventional approaches remain to be determined. Fenestrated and branched endografts are another viable alternative to median sternotomy for arch debranching, but they remain technically demanding from both a design and deployment perspective and are only available in the United States under a manufacturer or physiciansponsored investigational study. 14 FIGURE 3. Decision-making algorithm for hybrid TEVAR via RAM. TEVAR, Thoracic endovascular aortic repair; RAM, right anterior minithoracotomy; CABG, coronary artery bypass graft. The Journal of Thoracic and Cardiovascular Surgery c Volume 142, Number 2 317

5 CONCLUSIONS RAM is a compelling, less invasive technique for hybrid TEVAR according to the risk-benefit analysis. Further experience will be necessary to completely evaluate the merits of this approach. References 1. Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ, United Kingdom EVAR Trial Investigators. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010;20(362): Greenberg R, Haddad F, Svensson L, et al. Hybrid approaches to thoracic aortic aneurysms: the role of endovascular elephant trunk completion. Circulation. 2005;112: Hughes GC, Nienaber JJ, Bush EL, Daneshmand MA, McCann RL. Use of custom Dacron branch grafts for "hybrid" aortic debranching during endovascular repair of thoracic and thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg. 2008;136: e Milewski RJ, Szeto WY, Pochettino A, Moser GW, Moeller P, Bavaria JE. Have hybrid procedures replaced open aortic arch reconstruction in high-risk patients? A comparative study of elective open arch debranching with endovascular stent graft placement and conventional elective open total and distal aortic arch reconstruction. J Thorac Cardiovasc Surg. 2010;140: Younes HK, Davies MG, Bismuth J, et al. Hybrid thoracic endovascular aortic repair: pushing the envelope. J Vasc Surg. 2010;51: Donas KP, Czerny M, Guber I, Teufelsbauer H, Nanobachvili J. Hybrid openendovascular repair for thoracoabdominal aortic aneurysms: current status and level of evidence. Eur J Vasc Endovasc Surg. 2007;34: Francel TJ, Kouchoukus NT. A rational approach to wound difficulties after sternotomy: the problem. Ann Thorac Surg. 2001;72: Zhou W, Reardon ME, Peden EK, Lin PH, Bush RL, Lumsden AB. Endovascular repair of a proximal aortic arch aneurysm; a novel approach of supra-aortic debranching with antegrade endograft deployment via an anterior thoracotomy approach. J Vasc Surg. 2006;43: Aybek T, Dogan S, Risteski PS, et al. Two hundred forty minimally invasive mitral operations through right minithoracotomy. Ann Thorac Surg. 2006;81: Makaroun MS, Dillavaou ED, Wheatley GH, Cambria RP. Five years results of endovascular treatment with the Gore TAG device compared with open repair of thoracic aortic aneurysm. J Vasc Surg. 2008;47: Boonstra PW, Grandjean JG, Mariani MA. Reoperative coronary bypass grafting without cardiopulmonary bypass through a small thoracotomy. Ann Thorac Surg. 1997;63: Azoury FM, Gillinov AM, Lytle BW, Smedira NG, Sabik JF. Off-pump reoperative coronary artery bypass grafting by thoracotomy: patient selection and operative technique. Ann Thorac Surg. 2001;71: Ng PC, Chua AN, Swanson MS, Koutlas TC, Chitwood WR Jr, Elbeery JR. Anterior thoracotomy wound complications in minimally invasive direct coronary artery bypass. Ann Thorac Surg. 2000;69: Chuter TA, Hiramoto JS, Chang C, et al. Branched stent-grafts: will these become the new standard? J Vasc Interv Radiol. 2008;19(6 Suppl):S The Journal of Thoracic and Cardiovascular Surgery c August 2011