Alternative Approaches - Minimally Invasive Beating Heart Aortic Arch Debranching Instead of Extensive Arch Surgery

Objectives: Latest advances in treatment of aortic arch pathologies increasingly included endovascular techniques combined with surgical debranching to generate an adequate landing zone. Herein we report the results of an alternative surgical approach in a series of high-risk patients, whom were considered not suitable for extensive aortic arch surgery.

Patients and Methods: We report 15 patients presenting with pathology of the aortic arch, being treated with the technique as described below. In 5 patients a minimally invasive strategy by partial upper sternotomy and autologous graft material was pursued. Preoperatively all patients received computed tomography of the chest and great vessels. The procedures were performed by an interdisciplinary team consisting of cardiac surgeons, vascular surgeons and interventional radiologists. Pre-, intra- and postoperative data are presented.

Results: The procedures were performed in a hybrid OR. In a staged approach, first, the supra-aortic vessels were debranched using autologous material or Dacron prostheses without the use of extracorporal circulation. After this primary step, generating a landing zone, the procedure was continued by transfemoral implantation of a covered aortic stent. If not possible to transpose, the left subclavian artery was occluded by antegrade placement of an Amplatzer device. Five procedures were performed by upper partial sternotomy (Fig. 1). Surgical course was mainly uneventful in all patients. No intraoperative or hospital mortality was observed. All patients were characterized by a short postoperative recovery phase with successful weaning from the respirator on the first operative day. Follow-up care is performed by an interdisciplinary aortic board.

Conclusion: The described method represents a viable option in selected high risk patients. Avoidance of extensive surgery resulted in good clinical outcomes and short hospital stay.