Debranching of brachiocephalic trunk of DeBakey Type-I AoD followed by emergency TEVAR for subsequent aorto-esophageal fistula”- report of a case

Abstract

Object: Debranching of the aortic arch for an AoD with endovascular stent placement is an emerging surgical alternative for complex aortic arch involvement. This hybrid approach is relatively easy to perform than more complex surgical total and/or distal arch replacement.

Methods: We report a case of 66 yrs old Chinese gentlemen diagnosed as Debakey Type-IAoD, underwent - Replacement of ascending aorta &proximal arch [Gelweave 24 x 8mm], Debranching of brachiocephalic trunk [Uni-graft 10mm] and Aortic valve replacement [Epic Tissue Valve 23mm] with uneventful post-operative course. Discharged home with a plan to staged carotoid-carotid & carotid-left subclavian bypass with TEVAR zone-0 landing 4-6weeks later.

Result: Unfortunately 2 weeks later, the patient presented to A&E with Haematemesis, malaena and diagnosed as aorto-esophageal fistula. Emergency TEVAR done with cook ZTEG-2P-34-202 introduced and deployed at the origin of left subclavian balloon with CODA. An extension piece COOK ZTEG 40X 81 was introduced and deployed after left CCA origin. A third stent ZTEG 2pt 34-197 was deployed to just above celiac artery with proximal 3 stent overlap. No further leak noted into the false lumen. No complications like dysphgia, no haematemesis/haemoptysis. Discharged home at POD-6. Post-operative CT aortogram revealed no further leak.

Conclusion: Debranching of innominate artery is a relatively less complex surgical technique & less complicated for surgical trainees to perform, it is a suitable alternative with a favorable outcome. Even the emergency staged hybrid TEVAR is life saving and reduces the requirement of subsequent redo-sternotomy with supra-aortic vessels bypass.