Idrees et al Acquired Cardiovascular Disease

Hybrid repair of aortic aneurysm in patients with previouscoarctation

Jahanzaib Idrees, MD,a Amr Arafat, MD,a Lars G. Svensson, MD, PhD,a Daniel Clair, MD,b andEric E. Roselli, MDa

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Objectives: Hybrid operations combining open and endovascular techniques have evolved for patients withcomplex aortic and coexisting cardiovascular disease. Our objectives were to describe the repair techniquesand assess the outcomes in patients undergoing hybrid repair for aneurysm associated with previous aorticcoarctation.

Methods: From 2004 to 2012, 14 patients underwent hybrid repair by elephant trunk with endovascularcompletion (n ¼ 5), frozen elephant trunk (n ¼ 8), or antegrade stent grafting (n ¼ 1). The mean age at surgerywas 45 � 13.5 years. Of the 14 patients, 8 underwent supra-aortic arterial revascularization (ascending tosubclavian bypass in 5, carotid–subclavian bypass in 2, or ascending to carotid and subclavian bypass in 1).Ten patients had a bicuspid aortic valve, 5 underwent concomitant aortic valve replacement, and 1 underwentvalve repair. Six had a hypoplastic arch. Other procedures included ascending aortic repair (n ¼ 4), coronaryartery bypass grafting (n ¼ 1), ascending to descending bypass (n ¼ 1), and subclavian aneurysm repair(n ¼ 1). One operation was an emergency, the others were elective. The mean maximum aneurysm diameterwas 5.9 � 1.5 cm. Data were obtained from a prospective database and chart review.

Results:No perioperativemortality, stroke, renal failure, or paraplegia occurred. One patient required prolongedintubation, another required reoperation for postoperative bleeding. Two endoleaks required repeat intervention.The mean length of stay was 9 � 5.5 days. One late death occurred from hypertensive crisis and associateddisseminated intravascular coagulation. At a mean follow-up of 26 months, no aortic growth was found.

Conclusions: Hybrid repair of postcoarctation repair aneurysm is a safe and effective, less-invasive treatmentoption for patients with complex anatomy and/or concomitant cardiac disease. (J Thorac Cardiovasc Surg2013;-:1-5)

Coarctation of the aorta is common and comprises 5% to8% of all congenital heart diseases.1 Although associatedhypertension can lead to late complications, such as heartfailure and coronary and cerebrovascular disease, improve-ments in medicine have meant many survive late afterrepair.2

The additional late complications increasingly seen inthese patients have included aneurysms, recurrent coarcta-tion, and aortic valve dysfunction. Various methods ofrepair are available, including surgical and endovascularoptions. We have more recently preferred hybrid repair asa less-invasive treatment option for patients presentingwith complex anatomy, aneurysms, and coexisting cardiacdisease. Our objectives were to describe the indications

he Departments of Thoracic and Cardiovascular Surgerya and Vascular

ry,b Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.

ures: Authors have nothing to disclose with regard to commercial support.

d for publication Nov 26, 2012; revisions received Feb 25, 2013; accepted for

cation March 20, 2013.

for reprints: Eric E. Roselli, MD, Department of Thoracic and Cardiovascu-

urgery, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH

5-5108 (E-mail: roselle@ccf.org).

23/$36.00

ht � 2013 by The American Association for Thoracic Surgery

.doi.org/10.1016/j.jtcvs.2013.03.045

The Journal of Thoracic and C

for surgery and surgical technique and to assess theoutcomes in patients undergoing hybrid repair ofcoarctation-associated aneurysm.

METHODSFrom August 2004 to May 2012, 14 adults underwent hybrid repair of a

distal arch and/or proximal descending aortic aneurysm in the setting of

previous coarctation at Cleveland Clinic. The mean age at surgery was

45 � 13.5 years. All the patients presented with aneurysm associated

with coarctation, 6 had a hypoplastic arch, and 10 had bicuspid aortic valve

dysfunction or other cardiac comorbidities. Also, 13 patients had a history

of coarctation repair. The 1 patient without previous coarctation repair had

a history of trauma at the age of 16 and later presented with syncope at age

36. On chest imaging, pseudocoarctation and an 8-cm aneurysm was noted

distal to the left subclavian artery. The mean preoperative maximum aortic

diameter was 5.9 � 1.5 cm. The preoperative patient characteristics are

summarized in Table 1. The methods of repair included single-stage frozen

elephant trunk performed in 8 patients (Figure 1), elephant trunk with

endovascular completion in 5, and antegrade delivery of a stent graft in 1

(Figure 2). Ten patients underwent 12 concomitant cardiac procedures,

including aortic valve replacement in 5 and repair in 1, ascending to

descending bypass in 1, coronary bypass grafting in 1, and ascending aortic

repair in 4 (Table 2). Additionally, 8 patients required subclavian artery

revascularization. Carotid to subclavian bypass was performed in 2,

ascending to left subclavian bypass in 5, and ascending to carotid and

carotid to left subclavian bypass in 1. In all cases, the surgical approach

was through a midline sternotomy, and hypothermic circulatory arrest

was used in 13.

ardiovascular Surgery c Volume -, Number - 1

TABLE 1. Preprocedural patient characteristics (n ¼ 14)

Characteristic Total FET

ET

with EEC

Complex hybrid

reconstruction

Mean age (yr) 45 � 14 40 � 5 44 � 6 56

Men 11 (79) 5 5 1

Arch and descending

aneurysm

14 (100) 8 5 1

Previous coarctation

repair

13 (93) 7 5 1

Bicuspid aortic valve 10 (71) 4 5 1

Hypoplastic arch 6 (43) 4 2 0

Ascending aortic

disease

4 (29) 3 1 0

Coronary artery

disease

1 (7) 1 0 0

Data presented as mean � standard deviation or n (%). FET, Frozen elephant trunk;

ET, elephant trunk; EEC, endovascular elephant trunk completion.

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Repair TechniquesSingle-stage frozen elephant trunk. Single-stage frozen

elephant trunk was the most common hybrid procedure, performed in 8 pa-

tients. Initially, through a 5F sheath in the common femoral artery, retro-

grade wire access is obtained, and a 100-cm catheter was delivered into

the proximal ascending aorta. Fluoroscopic guidance allowed for accurate

navigation through the often tortuous anatomy. Midline sternotomy was

then performed, and the patient was cannulated either centrally or by

way of the right axillary artery for cardiopulmonary bypass and hypother-

mic circulatory arrest. During circulatory arrest, the aortic arch was

opened, and the previously placed 100-cm catheter was identified. A stiff

wire was then placed through the catheter to the femoral artery. The stent

graft was delivered antegrade in position across the diseased aortic

segment. After deployment, the device was sutured proximally into the

aortic arch.3 In the 6 patients with a hypoplastic arch, the arch was opened

longitudinally, and a patch angioplasty was performed with a piece of peri-

cardium to provide an aortic size compatible with the diameter of the

selected device. In patients with concomitant ascending aortopathy or car-

diac disease, the procedure was then completed by performing the more

FIGURE 1. Volume-rendered images (A) before and (B) after frozen e

2 The Journal of Thoracic and Cardiovascular Surger

proximal reconstruction. This usually involved an ascending repair with

an interposition graft, with or without a valve or root procedure (Figure 1).

Elephant trunk with endovascular completion. Elephant

trunk with endovascular completion, a 2-staged procedure, was performed

in 5 patients and was selected for those with more extensive disease.4 The

first-stage elephant trunk operation was performed through a midline ster-

notomy under hypothermic arrest. Open fenestration of the distal descend-

ing aortic landing zone was performed in 1 patient with chronic extensive

aortic dissection with aneurysm. The details of this procedure have been

previously described.5

The second-stage endovascular elephant trunk completion was per-

formed with a stent graft device delivered retrograde from the iliofemoral

access. Wire access into the elephant trunk graft was either obtained retro-

grade through the common femoral artery or antegrade from the right

brachial artery to secure a through and through wire access. One or more

stent grafts were then deployed into the distal portion of the elephant trunk

graft under fluoroscopic guidance and extended distally into the normal

caliber aorta at the distal landing zone.

Antegrade stent graft with complex hybrid reconstruc-tion. An antegrade stent graft with complex hybrid reconstruction was

used in 1 patient who had undergone his first coarctation repair with an

interposition graft at age 6 years. He developed repeat coarctation and un-

derwent a second repair, left subclavian to descending bypass, at age 25. He

presented to us at 56 years old with a pseudoaneurysm originating at both of

the anastomoses surrounding the previous bypass graft and minimal persis-

tent flow through the older and very stenotic interposition graft. He also had

severe stenosis of a bicuspid aortic valve. The operation involved hybrid

reconstruction through a median sternotomy on cardiopulmonary bypass

but without circulatory arrest. The multicomponent procedure included

ascending to descending bypass, bioprosthetic aortic valve replacement,

and the delivery of multiple stent grafts. Stent grafting was performed

both antegrade from the arch into the left subclavian artery and retrograde

from the descending aorta into the old interposition graft to seal off the

pseudoaneurysm6 (Figure 2).

Outcomes and Statistical AnalysisTechnical success was defined as fluoroscopic documentation of com-

plete exclusion of the aneurysmal segment of the thoracic aorta and the

absence of types 1 and 3 endoleaks at the conclusion of procedure. Given

lephant trunk procedure with patch angioplasty of hypoplastic arch.

y c - 2013

FIGURE 2. Antegrade stent graftingwith complex hybrid reconstruction. Illustration demonstrates (A) pre- and (B) postoperative anatomy before and after

hybrid reconstruction, respectively. C and D, Volume-rendered computed tomography reconstructions of the same patient before and after the procedure,

respectively.

Idrees et al Acquired Cardiovascular Disease

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the nature of hybrid repair, repeat intervention was defined as the need for

any additional unplanned procedure to address complications. Renal fail-

ure was defined as the need for hemodialysis, and respiratory failure was

defined as the need for reintubation or tracheostomy postoperatively.

Computed tomography was performed before hospital discharge. Follow-

up was performed as scheduled outpatient visits at 3 months and annually

and included imaging with computed tomographic angiography analyzed

using 3-dimensional reconstruction software (TeraRecon, San Mateo,

Calif) to assess graft patency, device integrity, endoleak status, and aneu-

rysm morphology.

Descriptive statistical analyses were used to present the variables for the

study. Continuous variables are presented as the mean� standard deviation

and categorical variables as percentages.

The Journal of Thoracic and C

RESULTSNo perioperative mortality and no stroke, spinal cord

injury, or renal failure occurred, but 1 reoperation wasrequired for bleeding. Three patients developed endoleaks.Two required reintervention, one with left subclavian arterycoil embolization for type II leak and another requiringadditional stent graft extension for a distal type I leak.The third type II endoleak from a segmental artery resolvedwith observation. At a mean follow-up of 26 months, 1 latedeath had occurred 4 months after the index operation. Thepatient developed a hypertensive crisis complicated by

ardiovascular Surgery c Volume -, Number - 3

TABLE 2. Operative details (n ¼ 14)

Variable Total FET ETwith EEC Complex hybrid reconstruction

Concomitant procedures

Ascending to descending bypass 1 (7) 0 0 1

Aortic valve repair 1 (7) 1 0 0

Aortic valve replacement 5 (38) 0 4 1

Ascending aortic repair 4 (29) 1 3 0

Coronary bypass 1 (7) 1 0 0

Mean CPB time (min) 153 � 10 158 � 15 128 � 19 165

Mean circulatory arrest time (min) 38 � 6 34 � 4 40 � 11 0

Stent graft type (n)

Cook-Zenith 9 4 4 1

Gore-TAG 2 2 0 0

Medtronic Valiant/Talent 2 2 0 0

Data presented as mean � standard deviation or n (%). CPB, Cardiopulmonary bypass; FET, frozen elephant trunk; ET, elephant trunk; EEC, endovascular elephant trunk

completion.

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disseminated intravascular coagulopathy and multiorganfailure. The exact cause for this event was unclear, but noevidence was found of dissection, and stent graft patencywas documented by computed tomography performed atthe time of crisis.

DISCUSSIONAneurysm formation is a frequent late complication in

patients with aortic coarctation with a lifetime incidenceof 11% to 24%.7-10 Reoperations in this populationpresent with challenges owing to the complexmorphology of the aneurysm, well-developed collaterals,intrapleural adhesions, and, in some cases, the need foradditional cardiac procedures. Our experience with hybridrepair has demonstrated the safety and effectiveness of aless-invasive option to manage these complications.

Open repair with redo thoracotomy is currently the stan-dard to manage late complications after initial coarctationrepair. However, it has a high risk of bleeding and resultsin mortality of up to 14%.8-10 Alternatively, endovasculartechniques have evolved as suitable treatment options;however, the use of stent grafts has been limited toselected patients with adequate aortic landing zones. Apurely endovascular strategy is not ideal in the setting ofa hypoplastic arch because of the lack of a reliableproximal landing zone or in patients with concomitantcardiac disease who require a multicomponent operation.2

Hybrid repair strategies offer the combined benefits ofboth open and endovascular repair options.11 The surgicalincision was either a mini- or median sternotomy in all pa-tients. This avoided the risk of bleeding from the chest wallcollaterals and the adhesions resulting from disturbeddissection planes from previous repair. The use of stentgrafts as a part of the hybrid reconstruction allowed for per-formance of the distal reconstruction without the need forredo thoracotomy. Sternotomy further expanded the optionsto perform concomitant procedures, such as aortic valve

4 The Journal of Thoracic and Cardiovascular Surger

replacement, coronary bypass, ascending to descendingbypass, and ascending aortic repair, as a part of a singleoperation. The hypoplastic aortic arch was also addressedthrough this approach by patch angioplasty during circula-tory arrest.

The choice of procedure was determined by the patient’sanatomy, disease extent, comorbidities and surgeon experi-ence. The elephant trunk with endovascular completion wasthe preferred procedure for patients with extensive aneu-rysm with dissection involving more distal aortic segmentsbecause of the concern for spinal cord injury. In contrast,patients with a hypoplastic arch or disease limited to the up-per half of the thoracic aorta were treated with a single-stagefrozen elephant trunk repair in which the proximal end ofthe stent graft was directly sutured into the aortic arch.Some patients with this disease have disease too complexto classify. One patient with 2 previous failed coarctation re-pairs and bicuspid aortic valve stenosis was treated with aparticularly complex reconstruction strategy with antegradestent grafting, ascending to descending bypass, and bio-prosthetic aortic valve replacement. This was done withoutcirculatory arrest and could only have been accomplished in1 stage using hybrid surgical techniques.

The limitations of any approach in patients with a historyof coarctation are related to the lifetime risk of late compli-cations. Although most of the stent grafts in the present se-ries were either directly sutured in position or fixed within awoven polyester graft, the long-term durability has not yetbeen determined. As such, all patients with a history ofcoarctation require lifetime imaging surveillance. Initially,the frequency of imaging should be high after repairs withan endovascular device; however, the imaging intervalscan be lengthened over time. The risk of missing a latecomplication after coarctation repair probably exceeds therisk of radiation exposure in patients older than 30 years.12

The surgical indications and clinical presentation oflong-term survivors of coarctation who develop aneurysms

y c - 2013

Idrees et al Acquired Cardiovascular Disease

are diverse. Hybrid repair offers a safe and effective lessinvasive treatment option for patients with complex anat-omy and/or comorbid cardiac disease.

References1. Cohen M, Fuster V, Steele PM, Driscoll D, McGoon DC. Coarctation of the

aorta: Long-term follow-up and prediction of outcome after surgical correction.

Circulation. 1989;80:840-5.

2. Kutty S, Greenberg RK, Fletcher S, Svensson LG, Latson LA. Endovascular stent

grafts for large thoracic aneurysms after coarctation repair. Ann Thorac Surg.

2008;85:1332-8.

3. Lima B, Roselli EE, Soltesz EG, Johnston DR, Pujara AC, Idrees J, et al. Modi-

fied and ‘‘reverse’’ frozen elephant trunk repairs for extensive disease and com-

plications after stent grafting. Ann Thorac Surg. 2012;93:103-9.

4. Svensson LG, Kim KH, Blackstone EH, Alster JM, McCarthy PM,

Greenberg RK, et al. Elephant trunk procedure: newer indications and uses.

Ann Thorac Surg. 2004;78:109-16.

5. Roselli EE, Sepulveda E, Pujara AC, Idrees J, Nowicki E. Distal landing zone

open fenestration facilitates endovascular elephant trunk completion and false

lumen thrombosis. Ann Thorac Surg. 2011;92:2078-84.

The Journal of Thoracic and C

6. Roselli EE, Soltesz EG, Mastracci T, Svensson LG, Lytle BW. Antegrade deliv-

ery of stent grafts to treat complex thoracic aortic disease. Ann Thorac Surg.

2010;90:539-46.

7. Bromberg BI, Beekman RH, Rocchini AP, Snider AR, Bank ER, Heidelberger K,

et al. Aortic aneurysm after patch aortoplasty repair of coarctation: a prospective

analysis of prevalence, screening tests and risks. J Am Coll Cardiol. 1989;14:

734-41.

8. Ala-Kulju K, Keikkinen L. Aneurysms after patch graft aortoplasty for coarcta-

tion of the aorta: long-term results of surgical management. Ann Thorac Surg.

1989;47:853-6.

9. Knyshov GV, Sitar LL, Glagola MD, Atamanyuk MY. Aortic aneurysms at the

site of the repair of coarctation of the aorta: a review of 48 patients. Ann Thorac

Surg. 1996;61:935-9.

10. Sakopoulos AG, Hahn TL, Turrentine M, Brown JW. Recurrent aortic coarctation:

is surgical repair still the gold standard? J Thorac Cardiovasc Surg. 1998;116:560-5.

11. Roselli EE, Qureshi A, Idrees J, Lima B, Greenberg RK, Svensson LG, et al.

Open, hybrid, and endovascular treatment for aortic coarctation and postrepair

aneurysm in adolescents and adults. Ann Thorac Surg. 2012;94:751-6.

12. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr, et al.

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for

the diagnosis and management of patients with thoracic aortic disease. J Am

Coll Cardiol. 2010;55:e27-129.

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Acquired Cardiovascular Disease Idrees et al

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000 Hybrid repair of aortic aneurysm in patients with previous coarctationJahanzaib Idrees, MD, Amr Arafat, MD, Lars G. Svensson, MD, PhD, Daniel Clair, MD, and

Eric E. Roselli, MD, Cleveland, Ohio

The surgical indications and clinical presentation in long-term survivors of coarctation who

develop aneurysms are diverse. Hybrid repair offers a safe and effective, less-invasive treatment

option for patients with complex anatomy and/or comorbid cardiac disease.

The Journal of Thoracic and Cardiovascular Surgery c - 2013