MINISTEROTOMY AND MINIMALLY INVASIVE HYBRID PROCEDURES FOR THE MANAGEMENT OF TRANSVERSE ARCH ANEURYSMS.

 L Pawlowski, J Pettit, L Harrison, CA Hinojosa, L Garrido-Olivares, L Carvalho-Perron, J Velianou¹, CS Cinà
 Division of Vascular Surgery and ¹ Cardiology, McMaster University, Hamilton, Ontario

Background:  Endovascular techniques are well established for the treatment of thoracic aortic pathology.  Innovative approaches are pursued in an attempt to extend their use to the transverse aortic arch
Objectives.  To present the results of hybrid procedures, using open techniques as an adjunct, to increase the applicability of endovascular repair of transverse aortic arch aneurysms.

Method:  This is a retrospective review of data collected prospectively, in a tertiary vascular centre with an established endovascular programme.  We included aneurysms of the transverse aortic arch in which endovascular procedures were used with the adjunct of open surgery (hybrid procedure). Transverse arch aortic pathology was classified according to the proximal landing zone in: zone 0 (proximal to the brachiocephalic artery), zone 1 (including the left common carotid artery), and zone 2 (including the left subclavian artery).  A ministernotomy was used to approach the ascending aorta, and cervical incisions were used for all other debranching procedures.

Results:  From February 2005 to November 2006, eight aneurysms involving the transverse aortic arch were identified in which debranching of the aortic arch was required before endovascular graft repair.  The indications for surgery were:  atherosclerotic aneurysms in six and a ruptured mycotic aneurysm in two patients. The open adjuncts included: three carotid-carotid-subclavian transpositions, one carotid-subclavian transposition, and four ascending aorta to brachiocephalic and left common carotid bypasses.  All patients survived and one with a ruptured mycotic transverse arch aneurysm suffered an embolic stroke which left him with moderate functional impairment.  At a median follow up of 317days (126 to 696 days) all patients were alive and the one who suffered a stroke is able to ambulate without a cane.
 
Conclusions: Ministernotomy is an effective approach to aortic arch debranching, and hybrid procedures, either a staged or in the same sitting, appear to be safe and effective to treat pathology of the transverse arch.