1. Surgical Techniques of Debranching
in Hybrid Arch Procedures
Dr. Manoj . P
Lead Consultant, Aster Cardiac Sciences
Aster Med city, Kochi.

2. Background
• Aortic arch aneurysms present a particular challenge to endovascular
repair due to the involvement of supra-aortic vessels and the anatomic
curvature of the arch
• A variety of maneuvers have been recommended for thoracic endo
grafting to address the landing zone limitations imposed by the arch
vessels.
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3. • Repair of aortic arch aneurysm is technically demanding, requiring
complex circulatory management.
• Very large atherosclerotic saccular aneurysms of the arch are grave
markers of extensive arch and brachiocephalic atheromatous disease
• Represent high surgical risks for perioperative neurologic
complications
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4. Strategy for Arch Aneurysm
Debranched AEVAR
Arch and distal arch aneurysm
Open Surgery
Anatomical limitations
• Proximal neck
diameter 34 ~ 37mm, length 20mm
diameter 23 ~ 33mm, length 15mm
•Character of Aortic wall (ascending aorta)
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5. • Despite technical and technological improvements,
Open repair is associated with high mortality and morbidity mainly due
to DHCA and cerebral ischemia
• Pre-op comorbidities Poor outcome
• For patients unfit for conventional surgery , hybrid approach of aortic
arch debranching with re-routing of supra aortic trunk and exclusion
of pathological portion of aortic arch employing an endograft
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6. Anatomical exclusion criteria
• Proximal or distal landing zone maximum diameter >38mm or >46 in
case of planned aortic branching
• Proximal or distal landing zone length <20mm
• Circumferential calcifications or thrombus of the proximal or distal
landing zone
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7. Anatomical exclusion criteria cont…
• Inverted funnel shaped proximal neck with >3mm increase in
diameter from the proximal landing zone
• Prohibitive occlusive disease, tortuosity, or calcification of intended
access vessels or in the region of the intended fixation sites
• Angulation in the aortic arch or thoraco abdominal aorta that would
preclude the advancement of the introduction system
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8. Debranching AEVAR
• Proximal Landing Zone
Zone 0
Aor-RSCA-Lt CCA-LSCA bypass
Bil FA –RSCA-L CCA-LSCA bypass
Zone 1
R SCA-LCCA-LSCA bypass
Zone 2
RSCA-LSCA bypass
LCCA-LSCA bypass
Simple sacrifice of LSCA
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9. Surgical procedure-Zone 0
• Median sternotomy
• Isolation of the proximal right subclavian artery and the common
carotid artery (CCA) -- distal to the brachiocephalic bifurcation
• A ‘‘Y’’ graft is tailored using an 8- to 10-mm Dacron graft and a 6-
mm Dacron graft implanted in an end to-side fashion
• Systemic heparinisation, continuous EEG monitoring
• Controlled hypotension,
• Longitudinal arteriotomy with side clamp on ascending aorta
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10. Surgical procedure Zone 0 cont…
• Proximal end of the graft anastomosed to the ascending aorta
• Graft tunneled beneath the left brachiocephalic vein.
• 6-mm Dacron branch was anastomosed in end-to-end fashion to LCCA
• Stumps of the innominate A and left CCA oversewn and reinforced with
Telflon felt pledgets
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11. The incision wound sternum was separated and
curved to right 6th intercostal space.
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13. Preparation of Aortic Band
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14. TOTAL DEBRANCHING AND AORTIC BANDING
WITH GORETEX GRAFT
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15. Previous elephant
trunk
Replaced
proximal aorta
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16. A) Preoperative CT scan demonstrates
a zone 0 aortic arch aneurysm. (B) Postoperative
CT scan demonstrates complete exclusion of the
aortic arch aneurysm after total rerouting of the
supra-aortic trunks.
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21. Ao-rt.SCA-lt.CCA-lt.SCA bypass
Approach : Median sternotomy
Inflow : Side clamp of Ascending Aorta.
Prosthesis : 12mm Hemashield for rt. SCA
8mm Hemashield for
lt.CCA & lt.SCA
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22. Surgical procedure-Zone 1
• 2 Anterolateral incisions
• 6 or 8mm PTFE ringed armed graft from donor carotid (end to side)to
recipient carotid in an end to end fashion
• CCA ligation to prevent Type II endoleak
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23. (A) Preoperative CT scan of a zone 1
aortic arch aneurysm. (B) Postoperative CT scan of
partial rerouting of the aortic arch with a right
common carotid-to-left common carotid-to-left
subclavian artery bypass and complete exclusion
of the aortic arch aneurysm.
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24. Indications for LSA revascularization
• Coronary circulation supplied by the LSA through the LIMA
• Inadequate contralateral vertebral artery
• Young patients
• Left handed professionals
• High risk for spinal chord ischemia
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25. • Multicenter study shows LSA revascularisation is indicated in 25-30%
of cases
• 498 cases of intentional LSA coverage without revascularisation in
TEVAR
- Stroke rate 2.6%
- Paraplegia 1.6 %
- Type 2 endoleak 1.2%
- Subclavian steal syndrome 10%
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26. NECKLACE GRAFT
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28. Surgical procedure – Zone 2
• LSA revascularization only in selected cases
A) Preoperative CT scan of a zone 2
aortic arch aneurysm. (B) Postoperative CT scan of
a carotid-to-subclavian bypass, occlusion at the
origin of the left subclavian bypass, and complete
exclusion of the aortic arch aneurysm.aster medcity

29. Summary
• Hybrid procedure for treating aortic arch pathology is feasible in
selected patients unfit for conventional surgery.
• The outcomes are promising, but the associated mortality and
morbidity rates are not negligible.
• Promising results  Evolving hybrid
Bearing on “FIT” patients for a
conventional surgery
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