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Thread: TEVAR with aortic debranching

  1. #1

    Default TEVAR with aortic debranching

    AAPC: Back to School
    Is anyone else doing this surgery

    Thoracic Endovascular Aortic Repair where they debranch the head vessels and re-implant them onto the aorta because the aortic graft cuts off the blood supply to the carotid, innominate and subclavian.

    Let me know- thanks

  2. #2
    Join Date
    Apr 2007
    WHills, CA

    Default TEVAR and graft

    Quote Originally Posted by cmweyand View Post
    Is anyone else doing this surgery

    Thoracic Endovascular Aortic Repair where they debranch the head vessels and re-implant them onto the aorta because the aortic graft cuts off the blood supply to the carotid, innominate and subclavian.

    Let me know- thanks
    What type of graft (tube) was used Dacron? Lots of Thoracic Surgeons performs this type of surgery, i think it's hybrid in nature, but check. It is used to better regulate the BP, because after an aortic dissection, if your BP isn't under strict control, one would hope to have their affairs in order. When i get back to work, I'll ask the guys and see what they say.

    I'm sure by the time I get back to this, someone would have been able to give you a better answer.
    Last edited by KellyLR; 08-16-2010 at 07:30 PM. Reason: add to

  3. #3


    Here is the OR note...

    Hybrid TEVAR with one left subclavian carotid bypass graft.
    2. Aortic debranching procedure done through a median sternotomy.
    3. Aortic stent grafting using a Medtronic Talent 40 x 40 x 114

    76-year-old male who previously
    a year earlier had a stent graft placed in a penetrating ulcer in
    his descending thoracic aortic aneurysm. At that time, he had a 4.5
    cm descending thoracic aneurysm at the level of the subclavian. Due
    to the large territory that had to be covered by a stent graft at
    that time, we opted to follow him. Over the past year, his aneurysm
    at the level of the left subclavian has grown to be 6.7 cm in size.
    After obtaining informed consent and discussing with the patient the
    various options versus open repair versus hybrid TEVAR procedure and
    the patient opted for the TEVAR approach due to the fact that we had
    no proximal landing zone and would have to create one.

    FINDINGS: Postoperative ejection fraction was 50%.

    PROCEDURE: He is taken to the operating room. The first order of
    business was his chest, legs and neck were prepped and draped in the
    usual sterile fashion. An incision was made 2 cm above clavicle on
    the left side and dissected down along the anterior border of the
    sternocleidomastoid. I identified the left internal carotid artery
    and got proximal and distal control. We also attempted to find the
    left subclavian through the same incision, however, his scalene
    anticus and brachial plexus was lower than expected and we wanted to
    avoid this area. So, we made an incision below his left clavicle on
    the left side, dissected through the subcutaneous tissues. I
    isolated the axillary artery and grafted it using an 8 mm Gore-Tex
    graft which was tunneled below, grafting the left subclavian to
    distal left subclavian artery bypass. Proximal anastomosis was sewn
    first. We flushed the graft prior to reestablishing flow. Once
    this was completed, we packed the incision. Median sternotomy was
    then performed. A pericardial well was created. His ascending
    aorta and head vessels were all identified and freed up. I
    skeletonized the innominate vein so I could move it back and forth.
    I then placed the partial occluding clamp. I took a 12 x 8 x 8 x 6
    Hughes graft. I sewed the proximal anastomosis after I tapered it
    and beveled it on the ascending aorta. I then took one of the 8 mm
    limbs and grafted the anastomosis to the left internal carotid
    artery. Once this was completed, we reestablished flow of the left
    carotid. I then placed a side-biting clamp on the innominate artery
    and grafted an additional 8 mm graft which had to be moved down onto
    the graft to have a better lie. Using a side-biting clamp, I
    performed my aortotomy and grafted the next head branch off the
    Hughes graft using a 4-0 Surgipro. At the completion of this, we
    reestablished flow. There is no bleeding and obtained hemostasis.
    We then brought in our fluoroscopy equipment, cut down on the right
    groin and got access to the right femoral artery. We got proximal
    and distal control. I placed a Lunderquist wire up from below.
    Through the sidearm graft with a Hughes graft under fluoroscopy, I
    was able to snare it and capture it. Then we had a Lunderquist wire
    from the femoral artery out the patient and the end of our Hughes
    graft. This straightened the aorta significantly. We were then
    able to bring our Talent graft up from below. Under fluoroscopy, we
    deployed it initially in the graft and released it. We had good
    coverage, good 3-4 cm proximal landing zone and deployed it into the
    distal previously placed graft. Our followup root shot showed no
    endoleak. Proximally, there was flow still coming in from the left
    subclavian. Our plan at that time was to place implants once the
    patient had fully recovered. We pressed the graft out with a
    balloon, pulled our devices out, and closed the femoral artery in
    the usual standard fashion. We placed 3 chest tubes, reclosed the
    pericardium, rewired the sternum and closed the subcutaneous tissues
    in 3 layers. The patient woke up neurologically intact. Followup
    CT showed just an endoleak from our subclavian which was dealt with
    by Dr. Clifford Lynd by placing an Amplatz plug later on.

    POSTOPERATIVE DIAGNOSIS: Descending thoracic aortic aneurysm 6.7 cm
    in size involving the left subclavian artery.

  4. #4

    Default Aorta debranching

    I would give this the following:

    Janet Kidneigh CPC, CCS

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