Alternative distal anastomosis during open thoracoabdominal aortic aneurysm repair for failed endovascular aneurysm repair

Central MessageThis alternative distal anastomosis contributes to reducing intraoperative complications during thoracoabdominal aortic aneurysm repair after previous endovascular abdominal aortic aneurysm repair. This alternative distal anastomosis contributes to reducing intraoperative complications during thoracoabdominal aortic aneurysm repair after previous endovascular abdominal aortic aneurysm repair. The number of open conversion surgeries (OCSs) after endovascular repair seems to be rising.1Georgiadis G.S. Argyriou C. Antoniou G.A. Nikolopoulos E.S. Kapoulas K.C. Schoretsanitis N. et al.Lessons learned from open surgical conversion after failed previous EVAR.Ann Vasc Surg. 2021; 71: 356-369Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar In thoracoabdominal aortic aneurysm repair (TAAAR) after endovascular repair, extensive dissection of the iliac artery and surrounding tissues might be more complex because the right distal common iliac artery is deep from the left thoracotomy and stent grafting increases adhesion with surrounding tissues, in turn decreasing mobility of the artery. We report an alternative distal anastomosis during TAAAR in OCS after endovascular abdominal aortic aneurysm repair (EVAR). An 80-year-old man presented with an enlarged suprarenal abdominal aorta that led to Type Ia endoleaks from the stent graft (Excluder; W.L. Gore & Associates) that was implanted 4 years ago. Although the patient underwent repeated coil embolization of the lumbar arteries for type II endoleaks at age 78 years, recent computed tomography (CT) scanning also showed type II endoleaks from the lumbar arteries (Figure E1). The aneurysm sac was gradually enlarged to more than 65 mm in size, and Crawford extent TAAAR was planned to manage both Type Ia and Type II endoleaks. The patient provided informed written consent for the publication of the study data. This article only involves a case report and was deemed exempt from our institutional review board approval. The aorta was exposed from the left thoracotomy and retroperitoneal approach. Then, partial cardiopulmonary bypass (CPB) was started via the femoral artery and vein. The descending native aorta was clamped segmentally and the aorta was opened. A proximal end-to-end anastomosis of a 22-mm 4-branched graft (J-graft; Japan Lifeline) to the descending aorta was performed using a running 4–0 polypropylene suture. Once the proximal anastomosis was completed, CPB was temporarily stopped and the distal clamp was released. The aneurysm was opened under lower extremity circulatory arrest. A thrombus in the aneurysm was removed, the terminal aorta was exposed from inside the aneurysm sac, and the main body and the bilateral limbs of the stent graft were partially removed (Video 1). Back-bleeding from the iliac arteries was controlled by 8Fr indwelling urinary catheters. After the lumbar artery that was causing type endoleaks was oversewn, the thrombus at the terminal aorta was carefully removed. Bilateral limbs of the stent graft were fixed with the native aorta using 5–0 polypropylene with a small pledget to prevent the stent graft legs popping out from the aorta (Figure 1, A). A 4-branched vascular graft was anastomosed to the newly reconstructed terminal aorta suturing the bilateral iliac limbs and native aorta together using a running 3–0 polypropylene suture and the polytetrafluoroethylene strip outside (Figure 1, B). To prevent the gutter leak and the leak between the 2 grafts, the gap between the 2 limbs was closed to suture the limbs together (Figure 1, C). The CPB was then restarted for rewarming. Finally, all visceral arteries were reconstructed individually (Figure 1, D). The patient weaned from the mechanical ventilation support on 1 day after TAAAR and discharged home without any complications on day 22. Postoperative CT scanning showed no complications at the terminal aorta (Figure 2). Fenestrated or branched endovascular aortic repair for TAAA has been reported with acceptable short-term outcomes.2Rocha R.V. Lindsay T.F. Austin P.C. Al-Omran M. Forbes T.L. Lee D.S. et al.Outcomes after endovascular versus open thoracoabdominal aortic aneurysm repair: a population-based study.J Thorac Cardiovasc Surg. 2021; 161: 516-527Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Endovascular repair would be desirable for elderly persons with multiple comorbidities. Repeated endovascular intervention resulted in fail; therefore, OCS with Crawford extent TAAAR was performed to manage both type Ia and type II endoleaks. Surgical techniques during OCS have been described, including open median laparotomy after EVAR and left thoracotomy after TEVAR.1Georgiadis G.S. Argyriou C. Antoniou G.A. Nikolopoulos E.S. Kapoulas K.C. Schoretsanitis N. et al.Lessons learned from open surgical conversion after failed previous EVAR.Ann Vasc Surg. 2021; 71: 356-369Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,3Canaud L. Alric P. Gandet T. Albat B. Marty-Ané C. Berthet J.-P. Surgical conversion after thoracic endovascular aortic repair.J Thorac Cardiovasc Surg. 2011; 142: 1027-1031Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 4Coselli J.S. Spiliotopoulos K. Preventza O. de la Cruz K.I. Amarasekara H. Green S.Y. Open aortic surgery after thoracic endovascular aortic repair.Gen Thorac Cardiovasc Surg. 2016; 64: 441-449Crossref PubMed Scopus (37) Google Scholar, 5Perini P. Gargiulo M. Silingardi R. Bonardelli S. Bellosta R. Piffaretti G. et al.Multicenter comparison between open conversions and semi-conversions for late endoleaks after endovascular aneurysm repair.J Vasc Surg. 2022; 76: 104-112Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Stent grafting induces an inflammatory response around the aorta and increases adhesion to surrounding tissues, decreasing mobilization of the iliac artery.6Rinaldi E. Kahlberg A. Carta N. Mascia D. Bertoglio L. Chiesa R. Late open conversion Following failure of EVAR and TEVAR: “state of the art”.Cardiovasc Intervent Radiol. 2020; 43: 1855-1864Crossref PubMed Scopus (14) Google Scholar This is also related to high bleeding rates and prolonged procedure duration. Total graft removal is therefore challenging in OCS and partial graft removal has been the focus of reducing postoperative morbidities.4Coselli J.S. Spiliotopoulos K. Preventza O. de la Cruz K.I. Amarasekara H. Green S.Y. Open aortic surgery after thoracic endovascular aortic repair.Gen Thorac Cardiovasc Surg. 2016; 64: 441-449Crossref PubMed Scopus (37) Google Scholar In this report, distal anastomosis with partial removal of the stent graft was focused on in OCS. Compared with standard TAAAR with bifurcated Y graft replacement for TAAA and AAA, extensive dissection of the iliac artery and surrounding tissues might be more complex in OCS because mobilization of the iliac artery with the stent graft limb is restricted. In addition, the potential risk of sexual dysfunction should be kept in mind. Our procedure avoided such complications to create a new double-barreled terminal aorta with minimal dissection around bilateral iliac arteries. Back-bleeding from the iliac arteries could be completely controlled using indwelling urinary catheters. Among the concerns in this technique is a gutter leak between the limbs. To achieve secure anastomosis, bilateral limbs of the stent graft were fixed to the native aorta to prevent migration of the stent graft. During the distal anastomosis, the bilateral limbs were fixed together using a running suture of 3–0 polypropylene to close the gap. Postoperative CT showed secure double-barrel passage at the terminal aorta without any obstruction or deformity of either leg of the stent graft. This procedure could not be applied in all cases. In the case of prosthetic graft infection, all components of the stent graft should be retrieved, although more extensive dissection might increase the risk of bleeding and technical complexity. Although the presence of Type Ib endoleaks or the lack of a sufficient landing zone for the limbs of the stent graft are contraindications for this procedure, hybrid repair, including TAAAR and endovascular repair with additional stent grafting might overcome these drawbacks. This alternative distal anastomosis with partial resection of the stent graft might contribute to reducing intraoperative complications during TAAAR in OCS for failed EVAR.