Our debranch first technique described by Dr. Niranjan Hiremath and was presented at CX Aortic in Vienna in October. Hoping to collect multicenter experience with this technique.
Link to original blog article regarding this case
Link to journal article.
At CCAD, during my 4 years here as chief of vascular surgery, I had the privilege of working with excellent colleagues in a world class facility in an amazing and generous host nation. Over that time, our operative case volumes grew rapidly (figure below) as we proved our worth.
Our unique situation as both a main campus of Cleveland Clinic and a startup in 2015 with a fraction of the systems already in place at Cleveland made innovation a necessity. When making do became making great, we achieved the world class results as we were tasked to do. I count 5 off the top off my head in vascular, but there are many more that we do every day, contributed by all the team members. It is in the Cleveland Clinic’s DNA, from its origins century ago in the vasty fields of wartime France, this systemic mission to make things better. I think a lot of how our founders worked from necessity near the trenches in operating theaters within tents, sleeping on rough cots, thousands of miles from Cleveland. It is working in a startup hospital here, a stunning facility endowed by the Emirate of Abu Dhabi, that I realized that practical innovations were the lifeblood of hospitals in times past, and that it continues to have meaning when lives are saved. In a world where costs, not ideas, will, or skills, limit the availability of healthcare, cost innovation will play a large role in its salvation.
Innovation #1: Debranching Thoracoabdominal Aortic Aneurysm
The thoracoabdominal aortic aneurysm (TAAA) is the most challenging operation to do either with open or endovascular approaches because of the complications associated with the procedure including bleeding, kidney failure, spinal cord ischemia, and death. You really can only get good by doing a lot of these regularly, as it brings with it precious experience for the OR, ICU, rehab, and floor staff. The patients with TAAA presenting to CCAD do not always have the opportunity to travel to one of the acknowledged aortic centers (with which each of the faculty here have close ties), and we must offer results that match those other centers. To me, the biggest hassle and source of complication with an open TAAA repair is the drying up of bleeding at the end of the case, the result of long visceral clamp times. Long procedure time prolongs the case and exposes the patient to a more turbulent and prolonged recovery and higher risk.
Endovascular repair with branched or fenestrated stent grafts offers one solution in avoiding the thoracoabdominal exposure and long procedure times. Unfortunately, a significant minority of patients do not have the anatomy for endovascular approaches. We have the skills, staffing, and facilities to offer both approaches, but are handicapped by low volume. Review of our volumes show that aortic aneurysm disease is dwarfed by diabetic circulatory problems. So to offer these patients the same results with open aortic surgery as the patients I had at main campus in Cleveland, I had to cheat a bit by rearranging the deck. How so? By turning the highwire act of thoracoabdominal aortic aneurysm surgery and turning into a deliberate walk on a low balance beam. By debranching the visceral branches from the graft one by one, the visceral ischemia time is minimized (video) or largely eliminated.
I discussed this with Dr. Niranjen Hiremath, our aortic trained clinical associate and like all things in medicine, a similar concept was applied by his mentor, Dr. Matalanis in Australia, to the aortic arch. We have performed two of these and both patients survived and are doing well, including the most recent one with a hybrid extant 2 repair. We published the technique after the first case in Journal of Thoracic and Cardiovascular Surgery (figure below, reference 1). I also presented the first case on this blog (link). More gratifying are the reports of adoption of this technique around the world. The patients come out of the operation without the torrent of coagulopathic bleeding seen with the traditional technique.
Innovation #2, The Vascular Lab in Every Patient’s Room
One of the things that happened early in my tenure was realizing how limited the tools available for vascular assessment were for non vascular caregivers. Both the physical examination with pulse palpation and pulse Doppler examination are challenging to master and usually fail to answer the simple question: is there enough perfusion? The absence of a pulse or Doppler signal in the hands of a non-vascular caregiver is an inconstant thing, and various projects have been undertaken that do not specifically address the triage gap that vascular surgery has compared to cardiology for chest pain. Not all chest pains are referred to cardiology. Only those those patients who pass the screening test of EKG and serum troponin levels are referred. My first inclination was to budget for pulse volume recording machines to be located in the ED and ICU’s of the hospital, but it was not a simple solution and would require stretching the limited vascular lab staff. Then it dawned on me that the toe waveforms offered a solution. On the PVR machines, the toe waveforms are captured by transmitting red laser light through the nail of the toe. A receptor captures a waveform (figure below) that is reflects the passage of blood that absorbs that red light.
This is in fact the identical technology in a pulse oximeter which has extra circuitry to calculate an oxygen saturation. I was not interested in the saturation, but rather the waveform. It turns out, for all practical purposes, the waveform given by pulse oximeter units is qualitatively the same as that given by the pulse volume recorder’s digital plethysmograph (figure below).
So now, when I get a phone call from the ED that a patient has no DP or PT pulse, I ask the caller to place a pulse oximeter with a waveform trace on the patient’s second toe (or nearest extant toe). I then ask, is there a waveform? The presence of a waveform, no matter how dampened, means the patient does not face acute ischemia, and can safely wait until the morning, avoiding a drive in the middle of the night (figure below, severely dampened waveforms).
We are validating this with a study that has completed data collection and hope to present this simple test to a broad audience. This is something akin to having a point of care vascular lab study that can answer a simple question: is there blood flow at the level of the toes? The finer points of “how much blood flow” can be answered by formal testing but that keen absence of broad vascular assessment skills among healthcare providers and absence of a simple test like an EKG for MI will feel less sharp, particularly because of the near universal availability of a pulse oximeter with waveform display throughout most hospitals.
Innovation #3: Assessing for Visceral Malperfusion before Surgery for Aortic Dissection
The typical scenario for a sad ending is this: a patient undergoes emergency surgery for an ascending aortic dissection. The operation ends in the middle of the night. The morning labs show a lactate of 10 which had been rising since the end of the operation from a high borderline level of 2. The urine output also dropped to zero. The patient remains intubated and has palpable femoral pulses, but now has a distended abdomen full of bowel gas, and is unable to report pain. The decision is made to get a CTA on top of the ones the patient received preoperatively which nearly guarantees permanent renal failure and need for hemodialysis. The descending aortic portion of the dissection is noted to be causing a malperfusion of the SMA and left renal artery, and there is pneumatosis of the small bowel through transverse colon which are resected after revascularization. The patient recovers with a jejunostopy and lifelong TPN and hemodialysis. This sad scenario is what I thought about when I was asked to assess a patient intraoperatively without a femoral pulses after an aortic dissection for possible visceral malperfusion. The question was if CT with contrast was indicated. Having an RVT credential (I’m old), I frequently do my own scans, and have found under general anesthesia, the abdomen is easy to scan well. The patient is typically prepped from neck to toes for the operation, so sliding in with an abdominal probe was simple. It is possible to get excellent windows on the visceral segment abdominal aorta with long axis and short axis views of the celiac axis, SMA, renal arteries, and iiac and lower extremity arteries (figure below).
At CCAD, the patients also get a TEE, and the arch and descending thoracic aorta is well visualized. That first patient underwent a femorofemoral bypass for the lower extremity malperfusion, and I found that the left renal artery had obstruction, but the right did not. The patient was reassessed at the end of the case and good visceral perfusion was seen at that point. I realized I was onto something, and whenever possible now for ascending aortic dissections, myself or the vascular tech is called to evaluate the visceral and lower extremity arteries at the beginning of the case, avoiding contrast studies. We are submitting the experience as an abstract for the STS conference.
Innovation #4: Retrograde tibial artery distal perfusion cannulas for ECMO
This past year, ECMO has been lifesaving for many patients facing cardiovascular collapse from COVID and other conditions. Once the cannulas go in, a hypoxic patient in heart failure has a chance at recovery. The drama of the moment causes the caregivers to overlook the fact that up to 10 percent of patients without a distal perfusion cannula will develop leg ischemia, and that after 6 hours, irreversible will occur leading in neuromuscular death and limb loss. This has happened for two patients transferred for care this year. The problem is that the skill of placing a antegrade femoral artery distal perfusion cannula in the proximal thigh is not always present, and the ability to judge perfusion is degraded with ECMO flow. While older patients on ECMO may have significant arterial disease, young patients generally do not, and I saw that as an opportunity for simplifying the distal perfusion cannula by placing a 5F micropuncture sheath into the dorsalis pedis artery (figure below).
This provided sufficient flow to avoid limb loss in a series of patients on which we published a technical article (reference 2) and presented. The retrograde access of these supericial vessels is within the technical envelope of most intensivists and cardiologists, those who most frequently place emergency ECMO cannulae. It was gratifying to catch up with one of my first patients who walked in with both legs, having undergone a heart transplant while bridged with ECMO.
Innovation #5: Park Clamp Used in Thoracoscopic and Laparoscopic Surgery
The Park Clamp (link) is a circular compressor that is intended to compress bleeding tissues allowing for suturing within the circle. I invented this while at main campus, and missing it sorely, had two custom made at the prototyping facility at Cleveland Clinic and shipped into CCAD. It is particularly useful in venous bleeding during spinal exposures, redo groins around the profunda, and retroperitoneal tumor resection. Dr. Redha Souilamas, chief of thoracic surgery (image above) found it particularly useful in thoracoscopic pneumonectomies, when staple line bleeding is encountered on the pulmonary artery (image below).
In laparoscopic surgery, it is possible to introduce the compressor via a small incision and this will allow for laparoscopic suturing of a vascular injury in a bloodless field. I was able to resect an IVC tumor thrombus with Dr. Waleed Hassen using this device to achieve hemostasis. The critical feature of the Park Clamp, lacking a manufacturer, is that we made it ourselves in our own hospital.
Conclusion: a modest proposal or how cost innovation will save health care
Inventions and innovations exist in a vacuum unless they are implemented, and this requires the will to accept the possibility of a better way. You should never be satisfied with the status quo if there is harm to be reduced. There has to be buy in from everyone involved or you get the situation I had when I was a PGY-2 in 1995 in the ICU. Being the surgical ICU resident, I was called nearly hourly to change the dressing on a patient with HIV and necrotizing pancreatitis with an open abdomen. There was over a liter an hour of exudate soaking the dressings and pads, making it a nightmare for the nurses. After a third round of this and feeling it would interrupt lunch, I came upon a plan for covering the wound with lap pads, overlaying a chest tube, and sealing everything with an Ioban. With the chest tube to negative pressure via a Pleuravac, the calls to change the patient’s dressing ceased, and the nurses no longer hand to change the bedding hourly -bedding that was soaked with HIV positive exudate. I was very pleased about this until I was stat called to the director’s office. I was given the dressing down of my life -how dare I experiment on his patient and didn’t I think that placing a suction on the transverse colon would result in a fistula? I hung my head in shame and took down the dressing. Of course, readers will know that this preceded the VAC dressing by about a decade, and negative pressure wound therapy is now a multi-billion dollar industry. What it teaches me to this day is that progress only happens when success is actually seen by everyone, but also there has to be buy-in from the stakeholders -the people who bear responsibility for any bad outcomes -fistula and death in the case of this proto-VAC dressing. Without convincing everyone, there is no success, and the invention goes off to die.
The fact is, one time early in my tenure here at CCAD, we ran out of negative pressure pumps, and I placed this chest tube/Pleurevac dressing on a patient with a large groin wound that was leaking high volumes of exudate and lymph. After two days, when a VAC pump became available, the patient’s groin turned out to be clean and granulating and it came to me that the next great leap in innovation is low cost innovation.
Cost Innovation, to name it, is using what is available, sometimes repurposing, or at others, dialing back the clock, to replace costly things that threaten to break a hospital’s finances while maintaining quality. It was only a few generations ago when hospitals were self contained communities. Rather than use peel packs of disposable gowns and drapes, there were tailors, seamstresses, and launderers making and maintaining the same. The Mayo Clinic was making its own insulin after discovering it and gave away the recipe out of concern for ethics -out of believing it is wrong to profit from a life threatening condition. We have the technology and capacity to make low cost endoscopes and reprocess them -possibly undercutting current costs by a factor of a thousand. We slaughter millions of hogs and cows annually, but harvest no heparin from them in the US. Laser CNC cutters, 3D printers, and enthusiastic makers have proliferated and could make every item that we currently open from a peel pack, use once, and discard into landfills -one only has to look at the cottage industry of face shields and hand sanitizers that bloomed last year during the pandemic. Pharmacists are fully capable and trained to manufacture custom pills and compound salves and solutions by the gallons if only if they are allowed to, saving hospitals millions in cost of medications sold in blister packs and tiny tubes and bottles. Stents can be printed in-house, and stent grafts can be custom made (link). Every town or city has tradespeople who can work stainless steel, plastic, and glass, or make and program custom computers -it is a short jump to making medical equipment at scale in your hospital.
Cost innovation is the only way out for the inflationary cost cycle that has throttled healthcare throughout the world. We have become a world where healthcare is delivered out of peel packs and million dollar investments to perform single procedures is considered normal and desirable, almost to the point of thinking people as coming in disposable peel packs. When I watch shows about hospitals a century ago, such as The Knick, I don’t guffaw at the old-timey medical stuff. I see a fervent environment of innovation in purposeful communities of specialized workers within hospital walls. We need to return to such practicality if we are to break out of the plastic peel pack.
- Hiremath N, Younes H, Aleinati T, Park WM. Open repair of extent-III thoracoabdominal aortic aneurysm using a modified branch-first technique. JTCVS Tech. 2021 Mar 13;7:29-31. doi: 10.1016/j.xjtc.2021.03.014. PMID: 34318197; PMCID: PMC8312144.
- Göbölös L, Hogan M, Kakar V, Raposo N, Sänger S, Bhatnagar G, Park WM. Alternative option for limb reperfusion cannula placement for percutaneous femoral veno-arterial ECMO. Perfusion. 2021 Mar 26:2676591211003282. doi: 10.1177/02676591211003282. Epub ahead of print. PMID: 33765883.
Despite all the advances in endovascular repair of thoracoabdominal aortic aneurysms, no data shows their superiority in the mid to long term compared to open repair. That is why branched stent graft programs occur hand-in-hand with robust open surgical programs, to offer durable open solutions to younger healthier patients while mitigating risk in older sicker patients by going with a branched or fenestrated device. Despite these advances, clamp time and visceral ischemia persists as a challenge to safe performance of open thoracoabdominal aortic surgery. Even a straightforward group IV requires the surgeon to be swift. Time on an thoracic aortic clamp results in visceral ischemia with a predictable response of coagulopathy, acidosis, systemic inflammation, and renal insufficiency. Adding cardiopulmonary bypass mitigates some things (distal ischemia, normothermia, hypertension) but brings on other complexities (cannulation, circuitry, coagulopathy). Sewing to a Carrel patch allows one to perform one large anastomosis rather than four individual ones, gaining speed and time, but compromises by leaving aneurysmal tissue which could progress to a troublesome patch aneurysm. TAAA is a condition that demands referral to high volume centers. It is in high volume centers that these apex predator surgical conditions can be subdued. It is in these centers that branched/fenestrated stent graft programs can offer treatment for patients high risk for open repair. It is in these centers that patients can avoid compromises such as snorkels and chimneys. Unfortunately, these centers are long air flights away and the means of the patients may not match the desires. Out here in Abu Dhabi, half a world away from Cleveland, Rochester, Houston, Boston, Chapel Hill, New York, and Seattle, and over six hours from major centers in Europe, we usually have to find our own way. Thankfully, we have the resources in experienced staff and abundant materiel.
During my time at the main campus of Cleveland Clinic, I came to appreciate the hospital as a highly evolved tool for healing, but for open repair of TAAA, it still falls on the operating surgeon and the choices made that shaped the outcome. In this most invasive of operations, simplicity and efficiency translating to speed offers the only consistent path to success. My partner, Dr. Houssam Younes, who trained in Houston, mentioned that Dr. Joseph Coselli, has clamp times approaching 30 minutes for group II TAAA -an almost inhuman speed achieved by doing these cases every day. For this reason, stent grafts are popular because repair of aortic aneurysms can be achieved by more practitioners in widely distributed settings. Because of the marketing of all things minimally being better, patients come asking for endovascular.
The patient is a fifty-something smoker who had a prior type B aortic dissection nearly a decade past who presented with substernal chest pain radiating to the back. He was found on CTA (figure below) to have a 6.5cm extant V TAAA starting above the diaphragm and ending at the level of the renal arteries.
Closer inspection revealed it to be aneurysmal degeneration of the aorta at a large false lumen fenestration. The aneurysm had grown eccentrically into the patient’s right chest and retroperitoneum. The remaining dissection above to the left subclavian artery and to the aortic bifurcation was chronic and thrombosed. His pain waxed and waned with hypertension which initially had to be controlled with parenteral agents. His cardiac workup revealed normal ejection fraction and valve function, and no critical coronary artery disease on coronary CTA. Pulmonary consultation deemed him a low pulmonary risk for major surgery. I offered him open repair, and initially the patient balked, asking for an endovascular repair, but I carefully walked him through the concepts, principles, and data guiding my recommendation. Yes, in a rupture, I have stented and followed with visceral debranching (link) and we have placed multiple snorkels in a very high risk octogenarian with a rupture, but who would offer endovascular repair to an otherwise good risk 50 year old?
The operation was initially planned in the standard way with cell salvage, plan for clamping in the transition point where the descending thoracic aorta took a rightward turn. The sequence of operation was for proximal anastomosis, right renal anastomosis, cooling the left kidney, celiac axis (CA), superior mesenteric artery (SMA), left kidney, and finally distal anastomosis with reimplantation of any prominent intercostal vessels. Preop imaging suggested the one at the T12 level was large. CT surgery was asked to be available for cardiopulmonary bypass via left atrium and femoral vein. Cardiac anesthesia and I had a discussion about intraoperative monitoring and management. Plans were made for CSF drainage -despite recent papers suggesting as much harm as benefit from these drains, I still feel critical time is lost if the patient is ventilated for a prolonged period postop and motor evoked potential monitoring is not available. The culture of CCAD mirrors that of Cleveland Clinic’s main campus in Ohio, and collaboration is ingrained. It was also serendipitous that one of the clinical associates, Dr. Niranjan Hiremath, had a particular interest and training in aortic surgery and suggested something amazing.
The Game is Changed
Dr. Hiremath trained in both vascular surgery and cardiothoracic surgery in Melbourne under Dr. Matalanis. Drs. Matalanis and Ch’ng published a series of 5 patients done with a separate branched bypass to the visceral vessels fed from the cardiopulmonary bypass circuit (reference). A separate aortic bypass was then performed and this truncal visceral graft was anastomosed to the main aortic graft. It was a visceral branch application of what is commonly done for the aortic arch great vessels. It was clear to me that this concept eliminated the need for desperate speed, and minimized clamp time to the 5-15 minutes required for each visceral branch anastomosis. A game changer.
My process for incorporating new concepts to an operation requires comfort and familiarity. The familiarity with this modification had everything to do with my extensive use of shunts during peripheral bypass surgery. Placing the shunt into one of the renal branches of a 4 branch Coselli graft turns this graft into a live blood vessel. By fixing the proximal and distal ends of the graft in the correct orientation and position relative to the branches, each of the visceral branches could be anastomosed to the graft one at a time while the patient’s aorta remained unclamped. This is best described with the sketches I put together for the preop huddle (gif and figure below).
Even though I have done many of these operations, because of the smaller population at risk, thoracoabdominal aortic aneurysms are a relatively low frequency disease and no assumptions can be made. The fact was, it took very little convincing for me to understand this concept as a game changer, but I took the liberty of modifying it for the particular situation of the patient. Every operation is ultimately another quantum of experience for the people involved to take away priceless information for the next one which will always be unique. We must take these as opportunities for improvement. For once in a long time, I felt this would be a big improvement.
Day of Surgery
Our operations always start with a huddle, but this one was different because of the numbers of people involved. There were the cardiac anesthesiologists, some of the best I have ever worked with in my career led by Dr. Dominique Prudhomme. The cardiac surgeons, Dr. Tareq Aleneiti and Hiremath, who planted this idea, along with the perfusion team, cardiovascular nursing team, and my partner Dr. Younes walked through the steps of the operation with me, with bailout points and plans B and C (CPB with hypothermia and circulatory arrest as a last resort for any unforeseen uncontrollable bleeding). I felt like I was the ringleader in a heist movie, only in this case, rather than jewels, we were grabbing something actually priceless (figure 3).
The patient was placed in the right lateral decubitus position across the table break in the golf backswing position with pelvis relatively flat to the shoulders which were upright. The incision extended from the top of the sixth rib into the abdomen. This dissection is really two -the thoracotomy and separation of the peritoneum from the retroperitoneum linked by the takedown of the diaphragm and cutting of the costal margin. It is a tactile portion of the operation -only the hands really understand when to pull down and separate the two layers. The celiac and SMA are entangled in myenteric plexus which had to be cut to exposure sewable lengths of both. The left renal artery was also tricky in that the prior inflammation of the dissection resulted in stickiness of the tissues. It goes quickly and we have this exposure (figure 4).
The patient is heparinized with a goal ACT around 250. Not enough for CPB, but good enough for rock and roll. The cardiac surgeons placed a cannula within a double ring of advential sutures, cinched with Rummel tourniquets and secured with an 0 silk tie -a maneuver I did many times myself during my cardiac rotations in residency. This was placed on a Y connector, one branch going to the CPB pump in case of a need to go to plan C, and the other to a tubing connector inserted into the right renal artery branch of the Coselli graft -a slight modification of the original plan (figure 5).
The other branches were simply clamped and the aortic ends of the graft were rolled up with a straight Kelly and secondarily clamped with aortic clamps -this gave weight to the ends letting them be positioned in a way that kept the branches oriented properly. There is need for precision and prediction as everything rotates back 45-90 degrees and the viscera sit on the grafts and the anastomoses. That is why keeping some length is crucial -this length accommodates this rotation. The Coselli graft is opened to systemic pressure by releasing the shunt. The proximal and distal ends of the main graft are twisted and double clamped to position the graft branches in the correct radial and z-axis orientation.
The aortic and branch exposure with takedown of the diaphragm is a standard exposure. One technical difference for this procedure is the need to expose about 2cm of the CA and SMA. Typically, only enough to clamp the vessel is necessary in standard surgery as these vessels are prepared with aortic buttons or anastomosed as an island patch. These vessels are surrounded by myenteric nerve plexus which feels like fascia or scar tissue but can be divide. Use of a hook cautery typically used in laparoscopic surgery along with a Ligasure speeds dissection.
These arteries, starting with the left renal artery, are ligated at the origin and divided for end to end anastomoses to the Coselli graft branches. As these arteries are only briefly clamped for the anastomosis while the remainder are getting flow from the aorta or the shunted Coselli graft, visceral ischemia is minimized. I still chilled the kidneys with manual injections of cold Ringer’s Lactate via large syringes and Stoney injector tips. The final product is shown on figure 6.
The operation no longer felt like a sprint. The atmosphere was lively and relaxed -something that does not happen in these cases even at closing as exhausted residents or fellows focus on stitching together all the separated layers of the patient’s chest and abdomen. I played a soundtrack of classic Bollywood tracks, alternating between mellow and lively.
What was striking was the absence of the need for blood transfusion -about a liter and half ended up in the cell saver, and the patient received 2 units of plasma, out of tradition. The patient had a minimal brief plasma lactate elevation which did not persist. He was closed with a chest tube and brought to the cardiac intensive care unit, stable, not on pressors. He was extubated that night, and moved all of his limbs to command. The chest tube was removed on POD#2, and he left the unit to recuperate on the floor. Amazingly, his serum creatinine did not rise significantly. Prior to clamping he received the usual cocktail of mannitol but it was likely unnecessary. Most of these patients, even with revascularizing first after the proximal aortic anastomosis in the fastest of hands, there is at least 30 minutes of ischemia manifest postoperatively as a rise in the creatinine with recovery in most. This rise was brief and transient (graph).
In the visceral circulation, the ischemia in the normal open repair is manifest postoperatively as systemic inflammation requiring pressors, persistent lactic acidosis, and coagulopathy, which at best is transient but at worst, fatal. This patient had no significant shift in any of these parameters. He had his CSF drain removed POD#2 after clamping for 24 hours, and was discharged home POD#11, having to recover from right chest atelectasis and a blood patch placed for persistent headache. CTA prior to discharge showed a good result. The left renal graft had been on stretch but was rendered redundant on repositioning of the viscera. No stenoses were noted.
Of course we are writing this case up, but case reports by their form cannot be overly enthusiastic whereas on my personal blog I can be excited. The normal course of postoperative recovery, the ebb and flow taught in surgical critical care books, is a result of ischemia, blood loss and replacement, fluid resuscitation, and cardiopulmonary support. Add to that cardiopulmonary bypass and you get an additional hurdle for the patient to recover from. This technique of shunting reminds me most of the temporary axillofemoral bypass. When I was a fellow at Mayo, I assisted Audra Noel in taking an elderly patient with a 25% ejection fraction through open aortic surgery with nearly miraculous recovery largely by avoiding the factors that trigger the ebb and flow. This technique is easier but mandates a strong normal segment of thoracic aorta to serve as inflow, otherwise an axillary artery will need to be cannulated.
Spinal cord protection is made easier with this technique by avoiding the massive fluid shifts, the pressors, and the acidosis in a typical thoracoabdominal aortic aneurysm repair. The blood pressure and cardiac output were never seriously perturbed. Several large intercostals and lumbar arteries were encountered and they backbled so avidly, after the short operation that I really felt there was no need to revascularize them. The spinal drain was kept open only for a day, and kept another day clamped to ensure that it would not be needed before removing it.
If you accept that spinal cord ischemia is multifactorial, we had avoided those factors. The absence of massive blood loss, negligible pressor use, no fluid shifts, minimal ischemia, no significant acidosis, no prolonged OR and clamp times, no blood transfusions, and the presence of avid back bleeding suggesting strong collateralization, compelled me to end the operation without revascularizing these intercostal vessels.
The patient recuperated for an ten days after his operation but was walking from postoperative day #1. He had atelectasis due to mucus plugging in his right lung base and was treated for aspiration, but clinically did not have a pneumonia and his atelectasis cleared with chest physiotherapy and nebulizers and was discharged home. Gratefully, he has given us permission to discuss and study his case.
There is no success in these cases without a team, and we are blessed with talented caregivers. This technique greatly reduces the physiologic impact of this surgery on the patient, reducing the injury to the equivalent of a broad sword cut from chest to abdomen that missed all the vital organs and vessels. In the right hands, this concept will broaden the appeal of open repair of these challenging aneurysms.
Matalanis G, Ch’ng SL. Semin Thoracic Surg 31:8:708-12.
A basic recipe for treating complicated aortic dissection
It was only last month when I came across a post of an aortic aneurysm in a difficult spot (link) and I couldn’t help chiming in some comments. Reading it now, I sound insufferable, because I wrote,
“Depends on etiology and patient risk stratification. Also assuming aneurysm goes to level of SMA and right renal artery origins and involves side opposite celiac. Options depending on resources of your institute: 1.Open repair with cannulation for left heart bypass and/or circulatory arrest 2.Open debranching of common hepatic, SMA, R. Renal from infrarenal inflow and then TEVAR 3.FEVAR from custom graft from manufacturer on protocol 4.Parallel grafting to CA, SMA, R. RA with TEVAR 5.Surgeon modified FEVAR 6.Open Repair We would have a multidisciplinary huddle around this patient -Vascular, Cardiac Surgery, Cardiology, Anesthesia, and ID (if needed) to help choose. Be ready to refer to a center with more resources -including prepping patient for transfer and imaging -including uploading images to the cloud for transfer with patient’s permission. More info please”
More Info Please, Indeed
The post I commented on was of a saccular aneurysm in the transdiagphragmatic segment of aorta. Ironically, only a few weeks later, I got called from hospital transfer center about a patient with a leaking aortic aneurysm, a type V thoracoabdominal aortic aneurysm as it turned out, from an outside hospital, needing urgent attention, and we accepted in transfer based on the conversation I had with the tranferring physician. And that was the problem -usually in taking these inter-hospital transfers, you have to pray that the precious CT scans come along with the patient burned correctly onto a CD-ROM. You can buy and watch a movie in 4K resolution over the internet -about 4 gigabytes, but a patient’s CT scan which is about 200 megabytes -because of various self imposed limits, overly restrictive interpretations of laws, and lack of computer skills, these life saving images get transferred on CD in 2019. That last time I purchased a CD for anything was over 15 years ago.
An Interested Party
The technical solution –to use the internet to transfer critical life saving information between hospitals – came about when our IT folks took an interest in my quarterly complaint email about using the newfangled internet for sharing files. After mulling various solutions ranging from setting up a server to using commercial cloud solutoins, we came upon the compromise of using our internal cloud with an invitation sent to the outside hospital. I would send this invitation to upload the DICOM folder of the CD-ROM to an outisde email address. It was simple and as yet untried until this night. “Would the patient agree to have his CT scan information transmitted to us electronically?” I asked the other physician. He assured me that the patient was in agreement.
It Takes Two to Tango
Of course, being able to transfer these pictures requires a willing partner on the other side, and the referring physician made it clear he did not have the technical expertise to do so. It took a bit of social engineering to think about who would have that ability. Basically, aside from myself, who spend all their time in dark rooms in the hospital in front of giant computer monitors? The radiologists! I got through to the radiologist who had interpreted the report and explained the simple thing I needed. Gratefully, he agreed, and I sent him a link to our cloud server. I explained to him, “When you receive this, clicking the link opens a browser window and then you open the CD-ROM and find the DICOM folder and drag and drop it on the browser window.” The 200-500 megabytes of data then get sent in electronic form, as it was meant to in 2019.
The Internet Saves a Life
The brutal truth is that in locking down a computer system, many hospitals make it impossible to even load an outside CD-ROM, creating many self imposed barriers to care. Thankfully, at CCAD, we were able to work together to find a secure solution. With the CTA on our servers, I was able to review the study within 15 minutes of accepting the patient, and arrange for the right team to be assembled, and confirm that we had the right material (stent grafts) for treating the patient. When the patient arrived, OR was ready to go, saving hours of time that normally would have been required if the CT scan had to be reviewed from the CD-ROM that came with the patient. Sometimes, the CD-ROM does not come, and in a critical situation, the CTA has to be repeated with some risk to the patient for complications of the contrast and radiation.
What to Do
The patient had a 8cm sphere shaped aneurysm arising in the transdiagphragmatic aorta, leaking into the right pleural cavity.
The patient was otherwise a healthy middle aged man with risk factors of smoking and hypertension. The centerline reconstructions showed the thoracic aorta above the aneurysm to be around 20mm in diameter and same below, with the celiac axis and superior mesenteric artery in the potential seal zone of a stent graft. The only plaque seen was around the level of the renal arteries and was focal and calcified. Looking at the list I had made as a comment to the Linked-In post, I realized that I really only had one viable option.
Open repair, usually the most expeditious option, was made challenging by the right hemothorax, making a left thoracotomy hazardous if the lung had to be deflated. Cardiopulmonary bypass would have to be arranged for, and that adds a metabolic hit that greatly raises the stakes. Of the endovascular solutions, the only viable option was TEVAR to exclude the rupture and debranching of the celiac axis and superior mesenteric artery. To those who would advocate for parallel grafts, there was no room in the normal 20mm diameter aorta. And branch systems for rupture are some time in the future. Also, the patient was becoming hypotensive. So the planned operation was first TEVAR to stop the bleeding, and then open surgical debranching. A hybrid repair.
The smallest stent graft we have is a 21mm graft, but it would not be suitable for this aorta. In practice, the normal aorta is quite elastic and will dilate much more than what is captured on a CTA. The next size we have is 28mm graft and I chose this to exclude the rupture, which was done percutaneously.
As seen below, the graft excluded the celiac and SMA. Late in the phase of the final aortogram (second panel) there was an endoleak that persisteed despite multiple ballooning. The timing suggested the intercostals and phrenic vessels contributed to a type II endoleak, but it was concerning.
The bypasses were sent from the infrarenal aorta to the common hepatic artery and the SMA close to its origin, and the origins of the celiac axis and SMA were clipped. The bypasses were then done with a 10x8mm bifurcate Dacron graft originally for axillofemoral bypassing. It had spiral rings which I removed at the anastomosis and this resulted in a kink at the closer bypass. Usually, I loop this for iliomesenteric bypass but there was not enough distance from the infrarenal aorta. I have to add a little trick I modified from my pediatric surgery experience as a resident -a Heinecke-Mikulwicz graftoplasty:
This worked to relieve the kink as evidenced on the aortogram above. After closing the laparotomy, I placed a chest tube in the right chest. The patient had a course prolonged by a classic systemic inflammatory response syndrome, with fevers, chills, and leukocytosis. He bled for a while but stopped with correction of his coagulopathy. All blood cultures were negative, but a CT scan was performed out of concern for the endoleak, and the possibility of continued bleeding.
No endoleak was detected as the sac was fully thrombosed. There was a consolidation of the blood in the right chest, but it resolved with fibrinolytic therapy.
This case illustrates several points I have been making on this blog.
- Hybrid repairs are not some kind of compromise but the full realization of a complete skill set. When students ask me how to judge a training program, one of the best metrics is how frequently are hybrid operations performed. It means either the endovascularist and open surgical operator are in complete synchrony or there are individual surgeons competent in both open and endovascular surgery. Hybrid operations, rather than being a compromise, are an optimization.
- Time -Laying the stent graft across the celiac and SMA origins starts a warm ischemia clock. The liver and intestines, in my reckoning, should be able to tolerate the 2 hours of work to get the bypasses working. Cardiopulmonary bypass may give you less ichemia but at the metabolic cost of the pump time. These negative factors add up, but were surmounted by the fact that early control of hemorrhage was achieved. Stopping the bleeding and restoring flow are the core functions of vascular surgery.
- Planning and preparation. The ability to see the CT images and prepare the teams and materiel before the patient transferred was lifesaving. This is where our IT gets credit for responding to a critical need and formulating a solution that meets internal policies, external regulations, and saves a life. It illustrates so many opportunities particularly with electronic medical records and their processes which focus more on documentation for billing. A discharge summary should be multimedia like this blog post and it should be normal and easy to generate. And finally, as clinicians, we should mind technology with as much attention as we give to the latest medical devices and techniques.
I was invited by Dr. Martin Maresch to speak on complicated type B aortic dissections. Should be an exciting day.
The patient is middle aged and had a type B thoracic aortic dissection (TBAD) as a consequence of recreational substances that acutely raised his blood pressure. At the outside hospital, he had a CTA showing the dissection extending from his left subclavian artery and causing occlusion of his superior mesenteric artery (SMA). He developed abdominal pain and was swiftly transported to our acute aortic syndrome unit. He was taken to the operating room and underwent a TEVAR of the dissection and stenting of his SMA -this is similar to other cases I have discussed in prior posts so I am omitting the technical details. The stent covered the left subclavian artery origin to exclude the origin of the dissection. The stent was extended to the distal thoracic aorta but did not go to the celiac origin.
Post procedure, his lactate never rose and he was maintained on the usual post procedure protocol of keeping MAP’s (mean arterial pressure) above 80mmHg. His left subclavian artery was covered but I do not routinely bypass, especially when the left vertebral artery is at least equal in size to the contralateral one. I don’t often place spinal drains for urgent/emergent cases particularly in patients who have never had infrarenal aortic surgery and patent hypogastric arteries. He was kept sedated overnight and awoke in the morning unable to move his legs to command. He had no pain sensation up to his umbilicus.
A spinal drain was emergently placed and his blood pressure was raised to MAPs of 90+, but these failed to reverse his paralysis. After discussion among my world class partners, I chose to take the patient back for a carotid subclavian bypass which was done through a single incision with a dacron bypass graft.
His paralysis resolved. He was discharged home, ambulating without assistance. Spinal cord complications are reported to occur between 1-5 percent of patients undergoing TEVAR for complicated TBAD. They were seen in 2 of 72 patients in the TEVAR arm of the INSTEAD trial (Circulation, 2009 vol. 120(25) pp. 2519-28), and was permanent in 1. While there are some who routinely place prophylactic drains, it is unclear to me that they have a significant effect if placed unselectively. I will place a Preop drain in the instance of infra renal graft, hypogastric arterial occlusive disease. In the instance of a dominant left vertebral, I will perform concomitant bypass, but just as often not. This is a gratifying and rare outcome of paralysis reversed with a carotid subclavian bypass when spinal drain and permissive hypertension did not.
Type B aortic dissections (TBAD) are frequently seen here at the Clinic as we serve as a regional referral center. As a trainee, I read the chapters discussing all the classifications and discussions of the biomechanics and felt quite intimidated by the all the moving parts involved in an aortic dissection, and I missed the main point about TBAD. Aside from the rupture risk due to the attenuation of the adventitia and hypertension, the acute TBAD is a rapidly developing stenosis of the aorta due to the inflation of a wind sock balloon created by the dissection flap. You can assume any flow that occurs in the false lumen is limited by the area of the proximal tear which is always smaller than the area of the aortic lumen. The true lumen is still perfusing the lower half of the body, and because of the volume filling effect of the flap, flow is restricted. The equivalent physiology is seen in aortic coarctation. Long term, the false lumen behaves like a pseudoaneurysm and may thrombose, continue to grow, or both.
Our group looked at CT’scans on 80 consecutive patients and found that the true lumen to false lumen ratio of less than 0.37 is predictive of the need for intervention.
This makes hemodynamic sense as it approximates the 70% critical stenosis borderline for other arteries. It explains why closing the opening of the dissection, the opening of the wind sock, and expanding the true lumen effectively treats malperfusion.
This patient whose CTA is shown above was transferred with increasing abdominal pain, inability to control blood pressure, and worsening lactic acidosis.
There was nearly complete obliteration of the true lumen throughout the aorta and occlusion of the left renal artery and dissection into the celiac and superior mesenteric arteries.
Aortography showed the dissection, and absence of visceral vessels from the injection which was from the aortic root. True lumen position was confirmed with IVUS.
A thoracic stent graft was delivered across the left subclavian artery origin up to the innominate artery origin -the patient had a bovine arch. Immediately, there was filling of the visceral vessels with re-establishment of true lumen flow.
The renal occlusion appeared improved but there was still a stenosis due to deflated dissection flap and this was stented (panel right above).
His abdominal pain remitted and his lactate normalized. His creatinine stabilized and has since normalized.
Again, if the true-lumen is compressed, the aorta is stenotic because there is a wind sock inflated in it. TEVAR offers a minimally invasive option, frequently percutaneous, for treating this.
The figure above shows the summarizes the problem that brought the patient to his local hospital and triggered his transfer to our acute aortic syndrome unit. The concept is that all chest pain of cardiovascular origin gets intake through a vast intensive care unit staffed by cardiovascular intensivists. Stabilization, workup, transfer to operating room or interventional suite all happens in an ICU that encompasses almost a city block.
The patient is an older middle aged man with sudden onset of back and abdominal pain. He was on coumadin for a prior SMV thrombosis and treatment for a ruptured appendicitis -antibiotics with plan for staged appendectomy. CT at his local hospital revealed a type B aortic dissection (TBAD) that extended into his superior mesenteric artery.
The aortic dissection terminated in the infrarenal aorta. The celiac and SMA had true and false lumen perfusion, the right kidney was perfused through the false lumen, the left through the true. Both legs received true lumen flow.
The dissection started at the left subclavian artery origin. The false lumen compressed the true lumen up at the proximal descending thoracic aorta. This is an important finding because in this configuration with much of the filling of the dissection from the distal reentry sites, the false lumen acts like a pressurized, compressive lesion. With time, the adventitia around the false lumen may become aneurysmal if the false lumen fails to thrombose or obliterate. When the dissection is acute, the flap may cause a direct obstruction to flow or a dynamic one that depends on the pressure difference between true and false lumen.
In this patient, thrombosis occured in the SMA beyond the origin due to dissection and decreased flow. This was consistent with the patient’s complaint of generalized abdominal pain and examination findings of pain out of proportion to the exam, indicating acute mesenteric ischemia.
His laboratory findings were within normal ranges, indicating this was early in the process. It is important to remember that no lab value correlates with acute mesenteric ischemia except very late in the process, and acute mesenteric ischemia remains a clinical diagnosis (reference 1) that is associated with a high mortality rate.
He was taken to the hybrid operating room. Right groin access was achieved and wire access to the arch was achieved. IVUS (Intravascular ultrasound, Volcano) was used to confirm the location of the wire -I believe this is an important adjunct as simply passing the wire doesn’t guarantee travel up the true lumen.
A conformable TAG endograft (CTAG, Gore) was delivered through a 24F sheath into position. Two devices were used to cover the thoracic aorta from the left subclavian artery to a position immediately above the celiac axis. The left subclavian was partially covered -the bare stents covering the rest.
This excluded the proximal entry tear of the TBAD. IVUS (image below) showed improved lumenal diameter of the true lumen into the SMA.
Once this was done, wire access into the SMA was achieved. This was technically challenging from the groin, and the backup plan was access from the left brachial artery which had been prepped. With patience, 6French access into the SMA was achieved. The origin was stented with a balloon expandable 8mm x3cm stent -sizing was based on IVUS and CT. This creates an alarming arteriogram as the stent appears oversized on subsequent runs -it is important to remember that the false lumen still takes up space beyond. Arteriography located the thrombosed segment and the reconstituted SMA beyond.
Wire access was achieved across the thrombus. At this point, I had a range of options for thrombectomy including simply aspirating which retracting a catheter. This was not optimal as I could lose subsequent wire access or reenter the false lumen. The other option was an open thrombectomy and patch angioplasty -the thighs were prepped in case we had to harvest vein. Again, in the setting of dissection and going into the mesentery, an open revascularization while feasible, is challenging.
Thrombectomy catheters like Angiojet were available, but I chose to try the Export aspiration catheter (Medtronic). It is simple to set up and goes over a 0.14 wire. It is designed for the coronaries which have a similar lumenal diameter as the SMA. It worked well in this setting in retrieving thrombus which had a pale element that may have indicated some chronicity.
The completion arteriogram was satisfying.
The SMA completely filled as did the celiac axis and both renal arteries. I opted not to treat the right renal artery as we had given 250mL of contrast, and it was filling well without intervention. The patient was making excellent urine and his blood pressure had been maintained with mean arterial pressures above 70mmHg. At this point, IVUS confirmed good deployment of the stent.
The sheath was removed and the access site repaired. The general surgeons explored the patient and found all the bowel to be well perfused with pulsatile flows seen in the mesenteric arcade. The appendix was removed.
On waking, the patient was noted to not move his legs. A spinal drain was expertly placed by our cardiac anesthesia staff and his blood pressure was raised to MAP’s above 80. He recovered motor function in his legs soon after. I usually don’t place preop CSF drains in this scenario in the presence of good pelvic circulation, no history of infrarenal aortic interventions, and patency of the left subclavian artery. That said, with TEVAR of TBAD, there is a small incidence of paraplegia (1-5%) which I emphasize in my preoperative discussion.
He was started on heparin anticoagulation postop because of his history of SMV and now SMA thrombosis, interrupting it briefly to remove the CSF drain. A CTA was obtained to confirm absence of bleeding showing obliteration of the dissection in the aorta and good patency through the true lumen of the SMA.
Most importantly, he had complete relief of his abdominal pain.
The treatment of acute mesenteric ischemia has greatly evolved since I presented my paper in 2002. While open revascularization remains a gold standard, it is becoming increasingly apparent that good to better results may be obtained with an endovascular approach. Dan Clair, our chair, has made the comment that early revascularization with endovascular technique is analogous to emergent PTCA in occlusions of the coronary system and that re-establishing flow is a critical first step.
Open exploration still is the mainstay of managing acute mesenteric ischemia, but laparoscopic exploration remains feasible. This patient underwent open conversion after an initial laparoscopic exploration to remove a ruptured retrocecal appendix that had been treated for over a month on antibiotics. Without bowel necrosis, a second look is usually unnecessary, but is critical when threatened bowel is left behind.
- Park WM et al. J Vasc Surg. 2002 Mar;35(3):445-52.