The complete endovascular treatment of pathologies of the aortic arch and proximal descending thoracic aorta (TEVAR) reduces surgical trauma. The recently devel-oped chimney technique was successfully performed in our center in limited cases as double-chimney (triple-bar-rel graft) technique in the aortic arch. With respect to the transapical implantation of an aortic stent-graft, various groups have described antegrade transapical TEVAR (Ta-TEVAR) of both the ascending and descending aorta. 1-3 On the basis of these limited results, we undertook for the first time the application of triple-barrel technique by antegrade implantation of an aortic stent-graft through the transapical route of a beating heart to treat a contained rupture of the aortic arch caused by a penetrating aortic ulcer. CLINICAL SUMMARY A 76-year-old man with multiple comorbidities was seen for general weakness, long-lasting shortness of breath, and huskiness. Contrast-enhanced computed tomography re-vealed contained rupture of the aortic arch caused by a pen-etrating aortic ulcer with concomitant development of a pseudoaneurysm (72 mm; Figure 1). Cardiac surgeons re-jected conventional and hybrid procedures. Transfemoral TEVAR was not possible because of the 7-mm lumen of the abdominal aorta. TaTEVAR combined with a transcaro-tid and transaxillary approach for deployment of the chimney-grafts was therefore chosen. Approval for this pro-cedure was obtained from institutional review board. The procedure was performed with the patient under gen-eral anesthesia in the hybrid operating room with ceiling-mounted angiographic C-arm system and transesophageal echocardiography throughout the whole procedure. After a 5-cm minithoracotomy incision in the left sixth intercostal space, the pleura was opened and a pericardiectomy was performed, exposing the left ventricular apex. A pericardial pacing wire was placed to induce rapid pacing. Then 2 pledgeted U-shaped purse-string sutures were placed in the left ventricular apex. After administration of 10,000 units of heparin, the left ventricle was cannulated through an 18-gauge needle. A standard guide wire was advanced across the aortic valve. After the 6F multipurpose catheter was advanced over a 6F sheath, the standard wire was ex-changed for an extra Lunderquist double-curved stiff wire (Cook Inc, Bloomington, Ind). By changing the 6F sheath to a longer 24F sheath, passage of the delivery system of the aortic stent-graft (TGE373720 CTAG; W. L. Gore & As-sociates, Inc, Flagstaff, Ariz) to the proximal descending aorta was possible. Through short cut-down incisions, the left common carotid and right subclavian arteries were ex-posed and punctured. Then GORE Viabahn (10 3 100 mm) and Excluder (PXC181000) legs were inserted to the as-cending aorta guided by Amplatz super-stiff guide wires through 12F and 18F GORE DrySeal sheaths. Simulta-neously, the CTAG was introduced. The chimneys were introduced slightly deeper than the CTAG, with an overlap-ping length of 5 cm. Next, the main stent-graft—and, shortly after, both chimney-grafts—were deployed under rapid left ventricular pacing with heart rate of 180 to 200 beats/min with reduction of systolic blood pressure under 60 mm Hg to prevent the migration of the grafts (Figure 2). The left subclavian artery was not preserved due to only coverage of a short segment of the thoracic aorta. The completion angiogram showed no endoleaks and patent supra-aortic arteries. After withdrawal of all devices, the apex was closed with purse-string sutures. All incisions were closed in anatomic layers.
Shahverdyan, R., Madershahian, N., & Gawenda, M. (2013). A novel technique of antegrade transapical arch and thoracic aortic endovascular repair with a triple-barrel graft. Journal of Thoracic and Cardiovascular Surgery, 145(6), 1670–1671. https://doi.org/10.1016/j.jtcvs.2013.02.024