One stage repair in complex aortic disease: surgery combined with open distal stentgrafting requires a new stent graft design

Objectives: Combining surgery (ascending aorta and arch replacement) with distal open stentgrafting is a new method for one stage repair. However, standard stentgraft devices appeared to be inappropriate due to their stiffness, rigidity and poor steering-ability. We report our results using a stentgraft device developed for open distal stentgrafting.

Material and Methods: From 6/01 to 08/04 14 patients (mean age 57yrs, range 39–76yrs) underwent surgery for aortic pathology: Type A dissection 7 (acute 3, chronic 4), complicated Type B dissection 3, true aneurysm 4. Surgery was performed using hypothermic circulatory arrest and selective antegrade cerebral perfusion. After finishing the distal open anastomosis, stentgrafts were placed antegrade „open“ into the descending aorta. The true/false lumen flow was accessed by TEE doppler and by „on table“ fluoroscopy. Stentgraft development consisted in 4 steps. A) shorter and smaller introducer, B) reversed mounted stent, C) closed web design instead of open bar ends, D) vascular graft cuff proximally.

Results: All but 2 patients survived (86%). 1 patient died in the OR due to protrusion of the stent to the false lumen, one died on the 4th postop day due to rupture of the false lumen distally, both in the standard stentgraft era. The other patients are under close follow up (18; 3–36 months) and doing well.

Conclusions: The new stentgraft device allows for safe and reliable placement by improved handling and steering-ability, anastomosis to the arch prosthesis warranties the durable exclusion of the aortic pathology.