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Right Axillary Artery Cannulation for Endovascular Repair of an Acute Type A Aortic Dissection

Muetterties, Corbin E. BS; Conklin, Jeremy H. DO; Moser, G. William CRNP; Wheatley, Grayson H. III MD

Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery: March/April 2017 - Volume 12 - Issue 2 - p 140–143
doi: 10.1097/IMI.0000000000000350
Case Reports

Abstract: We present the case of a 48-year-old woman with an acute type A aortic dissection that was treated with thoracic endovascular aortic repair at our institution. The patient was found to have a focal type A dissection with pericardial effusion but no tamponade physiology and no involvement of the aortic valve or root. We elected to treat the patient's type A aortic dissection with an endovascular stent because of the patient's favorable anatomy and no evidence of neurologic deficits or signs of distal malperfusion. The patient was successfully treated with an abdominal aortic cuff deployed through the axillary artery. An axillary approach was necessary because of the short length of the delivery sheath preventing a transfemoral delivery. At 2-year follow-up, the patient remains free of complications with computed tomography scan revealing complete false lumen thrombosis and a stable endovascular repair. This report demonstrates a case of acute type A aortic dissection successfully treated using thoracic endovascular aortic repair and illustrates the utility of axillary cannulation for precise deployment of stent grafts in the ascending aorta.

From the Division of Cardiovascular Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA USA.

Accepted for publication January 25, 2017.

Disclosures: Grayson H. Wheatley, III, MD, is a consultant for Medtronic, Inc, Minneapolis, MN USA, Bolton Medical, Sunrise, FL USA, Lombard Medical Inc, Irvine, CA USA, and TriVascular, Inc, Santa Rosa, CA USA. Corbin E. Muetterties, BS, Jeremy H. Conklin, DO, and G. William Moser, CRNP, declare no conflicts of interest.

Address correspondence and reprint requests to Grayson H. Wheatley, III, MD, Centennial Heart & Vascular Center, 2400 Patterson St, #307, Nashville, TN 37203 USA. E-mail:

Aortic dissection is the most common fatal disease process of the aorta. Classification of aortic dissection is based on the location of the dissection. Currently, the treatment for type A aortic dissections is surgical therapy with resection of the diseased aorta and graft replacement of the ascending aorta. In recent years, there has been several case reports of thoracic endovascular aortic repair (TEVAR) used to treat type A aortic dissections in patients deemed too high risk for open-heart surgery. Access and delivery of stent grafts to the ascending aorta have most commonly been through transfemoral or transapical approaches. We present the case of a 48-year-old woman with an acute type A aortic dissection who underwent successful endovascular repair using right axillary artery cannulation as the vascular access for delivery of the endovascular aortic stent graft.

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A 48-year-old African American woman with a history of hypertension presented to her primary care physician's office with an acute onset of chest pain and focal seizure. She was transferred to our emergency department where she underwent a full workup and was found to be severely hypertensive, neurologically intact, and without signs of distal malperfusion. A computed tomography angiogram (CTA) of the thorax revealed an acute type A aortic dissection with a pericardial effusion (Fig. 1). The patient was immediately taken to the hybrid operating room where a transesophageal echocardiogram (TEE) was performed. The TEE revealed a moderate pericardial effusion without evidence of tamponade physiology. In addition, the TEE showed the aortic valve to be competent without evidence of aortic valve insufficiency. The aortic root was not involved in the dissection.

We elected to repair this acute type A aortic dissection using an endovascular approach because of a number of anatomic and physiologic variables. The patient was hemodynamically stable, the aortic pathology was confined exclusively in the ascending aorta, the aortic valve was competent, and the aortic root was not involved. Access to the aorta was gained via cut-down to the right axillary artery. An 8-mm graft was sewn to the right axillary artery and vascular access to the artery was obtained through the graft. A 20 French sheath was delivered into the ascending aorta through the right axillary conduit. An aortogram demonstrated no evidence of aneurysmal disease in the aortic root or ascending aorta. The aortogram confirmed the presence of the acute type A aortic dissection in the midascending aorta along the inner curvature. We delivered a 36 × 45-mm Gore Excluder Endoprothesis (W.L. Gore & Associates, Flagstaff, AZ USA) into the ascending aorta via the right axillary artery sheath and performed an aortogram with roadmap. Transesophageal echocardiography was used to help identify the proximal landing zone for the stent graft at the sinotubular junction (Fig. 2). Intravenous adenosine was then administered to obtain a brief period of asystole. The Gore Excluder Endoprothesis was deployed during asystole at the sinotubular junction. The patient's blood pressure was quickly restored after aortic stent-graft deployment. A complete aortogram demonstrated successful occlusion of the acute type A aortic dissection without endoleak (Fig. 3). An intraoperative TEE showed that the aortic valve was competent and there were no defects throughout the entire ascending aorta and root. The TEE also confirmed patency of the left main coronary artery. The pericardial effusion was drained using a percutaneous pericardial drain. The right axillary artery conduit was ligated and the right axillary incision was closed.

The patient remained hemodynamically stable and was extubated several hours postoperatively. She was neurologically intact and was discharged home on postoperative day 4. A postoperative CTA demonstrated successful endovascular repair of the ascending aorta (Fig. 4). She is followed annually with CTA of the thorax, and at 2 years post-procedure, the CTA confirms a stable endovascular repair (Fig. 5).

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Type A aortic dissections are life-threatening emergencies often requiring immediate surgical intervention. The International Registry of Aortic Dissection reports the overall in-hospital mortality for acute type A aortic dissections treated surgically to be 26.9%. The mortality for those treated with medical management alone is 56.2%.1 The criterion standard for treatment of acute type A aortic dissections has been resection of the damaged section of the ascending aorta and replacement with a graft. However, 30% of patients with acute type A aortic dissections are considered unfit candidates for open-heart surgery.1

In recent years, a number of case reports have demonstrated successful endovascular treatment of acute type A aortic dissections in patients who were considered high risk for traditional open-heart surgery.2–4 In one of the largest studies published to date, Lu et al. treated 15 patients using endovascular repair for acute type A aortic dissections. Thrombosis of the false lumen was achieved in all 15 cases. One new dissection, secondary to an entry tear in the arch, developed 3 months after the primary procedure but was successfully treated with a branched stent graph. No other complications or deaths were reported for a median follow-up period of 26 months.5

Endovascular repair of acute type A aortic dissections offers a number of advantages over traditional open repair. The first and most important is its avoidance of sternotomy and circulatory arrest. The minimally invasive nature of this technique makes it an appealing prospect for unstable or critically ill patients. Although the longevity of the procedure remains to be seen, we believe that a major application could be its use as a bridge to stabilize patients with acute type A aortic dissections. Once patients have stabilized, an elective repair of the ascending aorta could be completed using conventional techniques with greatly reduced risks as opposed to open-heart surgery on a patient in extremis.

In this case, we used the right axillary artery as our access point for the endovascular repair of an acute type A aortic dissection. This access was chosen because it allowed us to deploy an off-the-shelf abdominal aortic cuff. Abdominal aortic cuffs are designed for deployment in the abdominal aorta, and therefore, the delivery sheath is not long enough to reach the ascending aorta via a femoral artery approach. Using a right axillary artery approach, we were easily able to access the ascending aorta and deploy the abdominal aortic cuff at the precise location to occlude the entry point of the acute type A aortic dissection while preserving the competency of the aortic valve. An advantage of the right axillary artery approach is that the guidewire used to access the ascending aorta sits along the inner curve of the ascending aorta adjacent to the left main coronary artery. The trajectory of the guidewire and delivery catheter from a right axillary approach dictates that the aortic stent graft will open along the inner curve of the aorta, making deployment of the aortic stent graft more precise because the graft may be easily positioned superior to the left main coronary artery ensuring that the left main coronary artery is not covered. In a transfemoral approach, the guidewire sits along the outer curve of the ascending aorta away from the left main coronary artery making it harder to position a graft so as not to cover the left main coronary ostium. Another advantage the right axillary artery approach offers is the cannulated right axillary artery that can be used for cardiopulmonary bypass (CPB) if there is a need to switch to an open repair. In recent years, many surgeons have begun to adopt axillary antegrade perfusion as their preferred method of CPB because it helps avoid some of the complications presented by retrograde perfusion. These complications include elevation of the intimal flap and expansion of the false lumen, which can lead to organ malperfusion. Antegrade perfusion redirects blood flow into the true lumen and helps decompress the false lumen and avoid prolonged visceral ischemia.6 In a study by Moizumi et al.,7 they found that overall hospital mortality of patients undergoing repair of acute type A aortic dissections was reduced from an overall 15.1% to 7.2% in those patients who had received axillary cannulation for CPB. Therefore, axillary cannulation can serve as an effective entry site for endovascular repair and a pre-established bailout site for CPB should complications arise.

In conclusion, we present the case of a patient with an acute type A aortic dissection, which was successfully treated with TEVAR using an abdominal aortic cuff via a right axillary artery approach. In most cases in which patients have undergone endovascular repair for acute type A aortic dissections, the patients were deemed too high risk for open repair. In this case, the patient was not high risk, but the patient's anatomy was favorable for the use of minimally invasive techniques as a first approach. Furthermore, we were optimally prepared for potential conversion due to having arterial access through the right axillary artery. Of note, we performed this case in the hybrid operating room, which enabled and facilitated both endovascular and open approaches. As devices continue to be developed for the ascending aorta, and surgeons become increasingly skilled in endovascular techniques, we believe that TEVAR may prove to be an effective primary management for treating acute ascending aortic syndromes. Furthermore, as discussed, the right axillary artery may be the optimal vascular access point for successfully delivering endovascular technologies to the ascending aorta.

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Aortic dissection; Endovascular repair; TEVAR; Ascending aorta

©2017 by the International Society for Minimally Invasive Cardiothoracic Surgery