Selective cerebral extracorporeal circulation-enhanced total endovascular arch replacement using in situ fenestration

Abstract

In this article, we present a newly designed cerebral perfusion technique during the in situ fenestration procedure with three covered stent placement in an endovascular total aortic arch repair of a 68-year-old male patient. This technique enables the endovascular repair of the ascending aorta and aortic arch pathologies with commonly available thoracic aorta stent grafts in a safer and more effective manner.

Keywords: Aortic arch repair; cardiopulmonary baypas; cerebral perfusion; endovascular repair; in situ needle fenestration..

Figure 1. Preoperative computed tomographic images of the patient. (a) Three dimensional rendered images of the dissected aortic arch, and (b) three-dimensional sequence demonstrating a residual patent false lumen in the aortic arch with branch vessels.

Figure 2. Operative details. (a, b) Transesophageal echocardiography was placed preoperatively and helped physicians the precise deployment period; the tip of the stent graft delivery kit was advanced through the aortic valve into the left ventricle. (c) Extracorporeal circulation for selective cerebral bypass machines. (d) Angiogram during the procedure is demonstrated.

Figure 3. Operative details of the in situ fenestration. (a) Stent graft was positioned into the tubular graft. (b) Left common carotid artery fenestration under selective cerebral perfusion. (c) Right brachiocephalic artery fenestration technique via right common carotid artery. (d) Left subclavian artery in situ fenestration. (e) Additional thoracic aortic graft deployment. (f) In situ fenestration puncture tool kit.

Figure 4. Details of selective cerebral bypass circuit configuration.

Figure 5. Final angiogram presenting the thoracic stent positioned in the previously placed tubular graft, with triple in situ fenestration by covered stents to the brachiocephalic trunk, left carotid artery, and left subclavian artery.

Figure 6. Computed tomography images one week after the procedure. (a) A three-dimensional reconstruction of the aortic arch with triple stents in the brachiocephalic trunk, left carotid artery, and left subclavian artery. (b) Rendered image sequences clearly demonstrate the configuration of the three covered stents, (c) The patient’s incision lines after the operation.