Aortic arch de-branching for suspected expanding perigraft haematoma after previous acute type-A dissection repair with AMDS stent: A technique for a potential future problem

doi:10.21203/rs.3.rs-4009599/v1

Download PDF

Case Report

Aortic arch de-branching for suspected expanding perigraft haematoma after previous acute type-A dissection repair with AMDS stent: A technique for a potential future problem

https://doi.org/10.21203/rs.3.rs-4009599/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

Acute Stanford-A aortic dissections make up a large part of emergency cardiac surgery. They carry a significant burden of morbidity. New techniques to aid aortic remodelling include the Ascyrus Medical Dissection Stent (AMDS): Its increasing use, looks to present a potential problem in cases where surgery involving the aortic arch may be required.

Case Report:

We present the case of a 49-year-old male who underwent urgent redo-surgery for total arch replacement and de-branching following recent replacement of ascending aorta for acute type-A dissection where an AMDS stent was deployed. The patient underwent total arch replacement with a stented tri-furcate prosthesis and de-branching of arch vessels with the stent landed inside the previous AMDS, to good effect.

Conclusion

This case highlights a possible approach to aortic arch surgery in patients who have previous had AMDS insertion.

Acute Stanford-A aortic dissection

Ascyrus Medical Dissection Stent

Aortic Arch

Emergency surgery for Stanford-A aortic dissection (SAAD) carries a large burden of mortality and morbidity. There are different anatomical and technical variables to consider to each case, which ultimately dictate the extent of repair required, as such an individualised approach is often required. This ranges from root replacement all the way to total arch replacement. Closure of the false lumen should prevent the dissection from propagating further distally and result in remodelling of the aorta however it is noted that the intimal flap after conventional repair can create a new entry leading to false lumen pressurisation and collapse of the true lumen.

The introduction of the Ascyrus Medical Dissection Stent (AMDS), an uncovered expanding endovascular stent placed in the true lumen at zone 0 has aimed to improve the standard of care in type A aortic dissection (1). The device intends to limit and obliterate perfusion to the false lumen by sealing the distal anastomosis, thus promoting thrombosis. Mid-term results are strongly suggestive that AMDS facilitates positive remodelling of the aortic arch with safe and reproducible results shown in the Dissected Aorta Repair Through Stent Implantation trial (DARTS) (2, 3). The use of the AMDS device can cause a future problem. The device cannot be removed due to risk of damage to the native aorta. This poses significant technical difficulties when redo-surgery is required for the aortic arch.

We present a novel approach to aortic arch surgery in a patient who had a previously deployed AMDS who later required total arch replacement, to good effect.

A 49-year-old male, with a previous SAAD repair re-presented and was found to have a persisting false lumen. For his first presentation, he had a dissection involving his right coronary sinus extending down to the iliac vessels. He underwent reconstitution of the aortic root, repair the dissection flap, replacement of the ascending aorta with a size 28mm interposition tube graft and insertion of an AMDS stent into the descending thoracic aorta. CT aortogram post-repair showed a persisting false lumen. Interval imaging illustrated a strongly suspected expanding peri-graft haematoma from 4.5cm to 6.5cm. Subsequent, diagnostic catheter angiogram showed opacification of false lumen arising around the proximal end of the AMDS stent suggestive of ongoing leak (Fig. 1). Given the ongoing risk of the probable expanding haematoma, the patient was planned for urgent redo-sternotomy and replacement of the aortic arch to close the false lumen and obliterate the leak.

Figure 1. (A-B) CT aortogram showed an expanding perigraft haematoma (orange arrow). (C) Angiogram appearances suggest there is an ongoing leak at the proximal end of the stent with opacification of the false lumen arising around the innominate artery origin and propagating through the descending thoracic aorta into the thoracoabdominal segment. This runs from within the body of the stent, suggesting the body of the stent is patent.

Redo median sternotomy was performed without incident. Cannulation for cardiopulmonary bypass (CPB) was achieved centrally with core cooling to 22^oC. Dexamethasone administered at 27degrees C and ice packs to the head for cerebral protection. Antegrade cold blood cardioplegia was delivered into aortic root at 22^oCfollowed by initiation of circulatory arrest.

The arch vessels were dissected, and the previous ascending aortic graft was transected and trimmed back to the cuff of the AMDS stent distally. The suspected haematoma was found to be a seroma upon opening (Fig. 2A). The arch vessels were de-branched and ligated proximally. Cannulae were inserted into the innominate and left common carotid arteries to deliver direct antegrade cerebral perfusion. The left subclavian artery was difficult to access, so it was ligated temporarily. The frozen elephant trunk (FET) with trifurcate branches was deployed in through the AMDS and the covered stent expanded. The cuff was anastomosed to the previous teflon cuff of the AMDS in a continuous fashion.

The arch vessels were anastomosed to the trifurcate branches (Fig. 2B). Distal body perfusion via arterial cannulation of the graft sidearm. The proximal end of the graft was trimmed. The previous ascending aortic graft was also trimmed to the region of the sinotubular junction. Graft to graft anastomosis was then performed. The patient was weaned off CPB with inotropic and vasopressor support and the chest closed.

Figure 2. (A) Intraoperatively the suspected perigraft haematoma was actually a contained seroma, this was opened (blue arrow). (B) The repair involved a frozen elephant trunk with trifurcate graft. The original interposition graft was resented to leave a cuff just above the sino-tubular junction proximally. The elephant trunk device covered stent was deployed and expanded through the AMDS device and sutured in place. Arch vessels were debranched and anatomosed to the trifucate branches before a graft to graft anastomosis of the proximal and distal portions were completed.

Post-op CT aortogram showed good repair with obliteration of the seroma and no false lumen opacification (Fig. 3). The patient was discharged and reviewed in clinic without any issue and now remains for ongoing CT surveillance.

Figure 3. (A) CT aorta post repair shows resolution of the perigraft seroma with no contrast extravasation. (B) 3D reconstruction showing the covered stent in AMDS following insertion of the trifucate graft frozen elephant trunk.

SAAD is the most common cardiac surgical emergency with a high burden of mortality at 20% and morbidity. Patients surviving emergency surgery at risk of ongoing downstream aortic degeneration. There has being growing consensus that a more extended repair at the initial insult would limit this issue however, concerns over acute outcomes may limit the extent of repair considered safe by the surgeon (4).

Distal anastomotic new entry (DANE) is a pointed issue after SAAD causing a patent false lumen in the descending aorta (5). AMDS stents are a novel uncovered aortic arch hybrid graft implanted antegrade during hypothermic circulatory arrest to promote true lumen expansion and enhance aortic remodelling. Developed as an adjunct to standard surgical repair, they aim to improve malperfusion and promote remodelling of the aortic arch and distal dissected aorta at the time of initial surgery without complicating surgery (1).

The use of the AMDS is becoming more common in emergency practice, with a view to stabilise the true lumen and create a landing zone for thoracic endovascular aortic repair (TEVAR) options. Use of the AMDS device requires careful pre-operative planning to avoid central AMDS collapse(7).

AMDS stent use is contraindicated in patients with genetic aortopathy and nickel allergies as per the manufacturer: They should be avoided when tears extend into the arch. These cases should be managed by resection of the arch tear or obliteration with a covered stent following debranching procedure due to the risk of an ongoing patent false lumen. Despite promising results, the unknown issues surrounding redo-surgery for the aortic arch as well as a yet to be proven long-term clinical safety and efficacy, total arch replacement remains the best evidence based practice in SAAD involving the arch (6).

Surgical options for total arch repair in cases where an AMDS device has been inserted are somewhat unknown. The device itself cannot be removed, which can cause a significant problem should surgical re-intervention be required either due to persistent false lumen or leak. In this case, a covered endovascular stent was not an option due to the arch vessel patency and as such careful planning and multidisciplinary discussion helped to plan a surgical approach to debranch the arch and stablilise the false lumen. Re-operation with an AMDS in situ can present many technical challenges with the device also noted to distort the anatomy and create difficulty in accessing the arch vessels.

The AMDS device has ultimately shown promising results in studies so far in relation to aortic remodelling. As this case shows however, there are pitfalls to its use, including complicating the approach to further surgery involving the arch. Longer term data is required to clarify whether this arch management strategy improves late remodelling and reduces the need for further reintervention. The technical feasibility of reinterventions in the context of an in situ uncovered stent are also unknown however, we present one possible approach to good effect.

SAAD

Stanford-A aortic dissection

AMDS

Ascyrus Medical Dissection Stent

DARTS

Dissected Aorta Repair Through Stent Implantation trial

CPB

Cardiopulmonary bypass

FET

Frozen elephant trunk

DANE

Distal anastomotic new entry

TEVAR

Thoracic endovascular aortic repair

Ethics approval and consent to participate

Not applicable

Consent for publication

Consent of patient for publication of case and images gained

Availability of data and materials

Not applicable

Competing interests

Not applicable

Funding

Not applicable

Authors' contributions

RK: First author, image acquisition and editing. NS: Image acquisition, co-author. CD – Image acquisition and editing. RR – Proofing, co-author. A – Clinical supervisor.

Acknowledgements

Not applicable

Authors' information (optional)

Not applicable

Montagner M, Heck R, Kofler M, Buz S, Starck C, Sündermann S, et al. New Hybrid Prosthesis for Acute Type A Aortic Dissection. Surg Technol Int. 2020;36:95–7.
Bozso SJ, Nagendran J, Chu MWA, Kiaii B, El-Hamamsy I, Ouzounian M, et al. Midterm Outcomes of the Dissected Aorta Repair Through Stent Implantation Trial. Ann Thorac Surg. 2021;111(2):463–70.
Bozso SJ, Nagendran J, MacArthur RGG, Chu MWA, Kiaii B, El-Hamamsy I, et al. Dissected Aorta Repair Through Stent Implantation trial: Canadian results. J Thorac Cardiovasc Surg. 2019;157(5):1763–71.
Roselli EE, Vargo PR. Bare stenting of acute dissection: a gentle push forward. Eur J Cardiothorac Surg. 2023;63(3).
Tamura K, Chikazawa G, Hiraoka A, Totsugawa T, Sakaguchi T, Yoshitaka H. The prognostic impact of distal anastomotic new entry after acute type I aortic dissection repair. Eur J Cardiothorac Surg. 2017;52(5):867–73.
Al-Tawil M, Jubouri M, Tan SZ, Bailey DM, Williams IM, Mariscalco G, et al. Thoraflex Hybrid vs. AMDS: To replace the arch or to stent it in type A aortic dissection? Asian Cardiovasc Thorac Ann. 2023;31(7):596–603.
Luehr M, Gaisendrees C, Yilmaz AK, Winderl L, Schlachtenberger G, Van Linden A et al. Treatment of acute type A aortic dissection with the Ascyrus Medical Dissection Stent in a consecutive series of 57 cases. Eur J Cardiothorac Surg. 2023;63(3).

No competing interests reported.

Download PDF

Editorial decision: Revision requested
06 May, 2024
Reviews received at journal
06 May, 2024
Reviews received at journal
27 Apr, 2024
Reviewers agreed at journal
16 Apr, 2024
Reviewers agreed at journal
15 Apr, 2024
Reviewers invited by journal
15 Apr, 2024
Submission checks completed at journal
04 Mar, 2024
Editor assigned by journal
04 Mar, 2024
First submitted to journal
03 Mar, 2024

You are reading this latest preprint version

Aortic arch de-branching for suspected expanding perigraft haematoma after previous acute type-A dissection repair with AMDS stent: A technique for a potential future problem

Status:

Version 1

Abstract

Figures

Introduction

Case Report

Discussion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1