1. Aortic Pathology Angioclub Case Alex Copelan M.D. William Beaumont Hospital October 24, 2013

2. Chief Complaint And History Of Present Illness CC: Pain between shoulder blades HPI: 60 year-old male transferred from outside hospital’s Emergency Department after awakening earlier in morning with the sudden onset of severe “piercing” back pain radiating to his chest. He had never experienced similar pain. Pain was non-positional and unrelenting. He denied associated shortness of breath, syncope or pre-syncope, nausea or vomiting, and numbness or weakness. He denied illicit drug use.

3. Other Relevant History Past Medical History: Hypertension, Diabetes, Obesity, Atrial Fibrillation Past Surgical History: None relevant Social History: 40-year pack per day smoker, chronic alcoholism, no illicit drugs Family History: Hypertension (both parents) Medications: Carvedilol, Aspirin (325 mg/day), Metformin Allergies: None

4. Non-Invasive Imaging

6. Diagnosis And Panel Discussion Diagnosis: Ruptured thoracic aortic aneurysm, right-sided aortic arch with aberrant left subclavian artery Treatment Options – Total Aortic Arch Repair “Gold Standard” but requires cardiopulmonary bypass, complex circulation management and significant morbidity – Thoracic EndoVascular Aortic Repair (TEVAR) When implemented alone, mainly utilized for unbranched segment of aorta between left subclavian and celiac arteries – Hybrid Aortic Arch Repair Includes ascending aorta-based debranching or cervical extra-anatomical bypasses followed by stent-grafting Can be performed in higher-risk patients but not suitable in patients requiring cardiopulmonary bypass or in those with Type A dissections, and it is an extra- anatomical repair

7. Potential Complications of Intervention Total Aortic Arch Repair (compared to hybrid procedure) – Requires cardiopulmonary bypass and circulatory arrest whereas hybrid procedure does not – Increased operative time – Increased blood loss – Longer hospital stay Endovascular Stent Grafting – Must have sufficient proximal landing zones to avoid blockage of left or right common carotid artery and potential stroke Hybrid Procedure – Avoids cardiopulmonary bypass and circulatory arrest but still has associated complications – Renal impairment, respiratory failure, paraplegia, stroke, embolism, endoleak, and femoral access site complications

8. Intervention Hybrid Procedure: Aortic arch debranching using Dacron branched graft and endovascular stent grafting – Median sternotomy and exposure of aorta and great vessels – 10 mm straight Dacron graft was anastomosed to the body of a 16 mm x 8 mm bifurcated graft – 16 mm portion of the graft was anastomosed end-to-side to the ascending aorta – One limb of the graft was left long and anastomosed end-to-end to the right common carotid artery – Second limb of the graft was anastomosed end-to-side to the subclavian artery – Third limb of the trifurcated graft did not lie smoothly, therefore, a section of this was divided and anastomosed end-to-end to the left common carotid and then re-anastomosed to the main graft

9. Intervention Thoracic Aortography: Debranching and graft placement in the proximal ascending aorta (white arrow) allows for a sufficient landing zone for stent graft to repair the diseased aorta without threatening cerebral blood flow Calibrated pigtail catheter (blue arrow) placed in ascending aorta through right femoral approach and utilized in order to select appropriate stent size Left subclavian (green arrow), left carotid (purple arrow), right carotid (red arrow), and right subclavian (yellow arrow)

10. Intervention Lunderquist wire was placed through left femoral approach Introducer for endovascular prostheses was placed over Lunderquist wire Distally, a 40 x 15 Gore endovascular prosthesis was placed and then through this proximally a 45 x 20 endovascular prosthesis was placed Balloon angioplasty (yellow arrow) of stent grafts was performed Pigtail catheter was re-advanced into ascending aorta and angiography was again performed and demonstrated patent flow (red arrow) through the grafted vessels without evidence of endoleak

11. Summary - 60 year-old male presented with “piercing” back pain radiating to his chest -Non-invasive imaging demonstrated a ruptured thoracic aortic aneurysm and right-sided aortic arch with aberrant left subclavian artery -Treatment options included total aortic arch repair, TEVAR, and hybrid procedure -Patient was ultimately deemed best suited for hybrid procedure consisting of aortic debranching utilizing Dacron branched graft and endovascular stent grafting