Hybrid repair of aortic arch aneurysms
What is it?
When is this procedure indicated?
This surgery is indicated in aortic arch aneurysm cases (with or without associated dissection) located in zone 0 according to the Ishimaru classification, in patients with high surgical and anesthesiological risk.
How is it performed?
The intervention consists in the "debranching" of the supra-aortic trunks, revascularization of the same and finally endovascular exclusion of the aneurysm. Possible variants of the procedure: circulatory arrest surgery; surgical conversion of percutaneous accesses.
The intervention involves the following steps:
Step 1
placement of vascular plug to exc;ude the left subclavian artery from the circulation;
Step 2
debranching of the supra-aortic trunks through the packaging of a carotid-carotid or carotid-carotid-subclavian bypass;
Step 3
extra-anatomic revascularization of the supra-aortic trunks by packing a bypass between aorta and anonymous trunk in median sternotomy;
Step 4
placement of vascular endoprosthesis at the level of the aortic arch by percutaneous femoral access.
Recovery
After discharge, a home convalescence period of 1-2 weeks is still required before fully resuming previous activities. During this period, it is not uncommon to experience hyperpyrexia in the absence of elevation of indices of inflammation or organ localization; this is a condition known as Post-Implatation Syndrome. It is normal to feel rather weak and have no appetite. It is important to gradually resume physical activity, try to take short walks, with the goal of doing more each day than the previous day.
Short-term complications
Complications related to a surgery of this magnitude do exist, occurring with an overall frequency of about 20%. Complications can be trivial, such as infection or dehiscence of the surgical wound, urinary or respiratory infections, but they can also be very serious such as those listed below:
- Emergent need for surgical conversion due to bleeding or malpositioning of the endograft.
- Spinal cord ischemia conditioning definitive paraplegia/paraparesis characterized by sensory and/or motor disturbances in the lower limbs, sphincter incontinence and impotence.
- Aortic dissection: both of the ascending aorta (type A), sometimes involving the valvular plane and the ostium of the coronary arteries, and of the thoraco-abdominal aorta with involvement of the visceral and medullary vessels (type B); these events are burdened by a very high risk of death and require emergency surgical measures.
- Cardiovascular failure; respiratory failure; renal failure with risk of dialysis, even permanent; neurological deficits (upper and lower limbs plegia/paralysis) transient and/or permanent; transient or permanent cerebral stroke, both ischemic and hemorrhagic, both of the anterior and posterior circulation with hemiplegia, aphasia, dyslexia, disorders of consciousness, balance disorders, visual disturbances up to blindness, even permanent and able to determine total disability.
- Peripheral embolization (limbs, viscera): lower and upper limbs ischemia with risk of amputation, intestinal ischemia with need for extensive ileal and colic resection, acute pancreatitis on an ischemic basis with need for reintervention.
- Postoperative bleeding, even massive, with need for revision, capable of conditioning hemorrhagic shock and exitus.
- Multi-organ failure with exitus.
- Allergic reactions to the contrast medium; anaphylactic shock.
Long-term complications
- Dislocation of the endoprosthesis and increase in diameter of the aneurysm secondary to the onset of endoleak with need for reintervention or surgical conversion.
- Infection of the vascular prosthesis with need for surgical conversion reintervention and explantation of the infected graft.
- Possibility of ineffective exclusion of the aneurysm with expansion of the same over time and subsequent need for surgery and/or sudden rupture of the aorta and subsequent exit.
Where do we treat it?
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