Debranching Thoracic Endovascular Aortic Treatment for Aortic Arch Aneurysms

Abstract

About half of the thoracic endovascular aortic repair (TEVAR) cases require occlusion of major cervical branches. Therefore, the skill of debranching is essential to extend indication of TEVAR. It is not necessary to reconstruct the left subclavian artery (LSA) under other than special conditions, but it is safer to reconstruct the LSA in elective cases. The post-esophageal route of the common carotid artery bypass is cosmetically beneficial, but it has to pass behind the trachea membranous portion so as not to cause dysphagia. The triple vessels debranching from the ascending aorta for Zone 0 TEVAR with thoracotomy is not less invasive so that it’s not recommended much. Chimney method, in-situ fenestration (ISF), branched or fenestrated graft method could be used to avoid thoracotomy. For now there are no fenestrated nor branched grafts in Japan. ISF is a safe and effective way by employing our Squid capture method. During this procedure cerebral circulation is maintained by percutaneous cardiopulmonary bypass (PCPS). After deploying the stentgraft we stab it by a needle while squeezed by snare wire and stick a covered stentgraft eventually. Unlike chimney technique this method has no risk of gutter leak. The arch vessels’ debranching itself is not the risk factor of cerebral infarction. Pull-through is the strongest risk factor. The LSA blockade is most important in order to prevent cerebral complications. Complete isolation of cerebral perfusion with PCPS and the vertebral artery balloon protection is a final perfect way to prevent stroke.