From the Journals

Using CHIMPS for type A dissection in a high-risk patient

Publish date: November 1, 2016
By
Richard Mark Kirkner

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Gutter leaks, durability are challenges in CHIMPS method

In their invited commentary, Lars Svensson, MD, PhD, Matthew Eagleton, MD, and Eric Roselli, MD, of the Cleveland Clinic, said the approach Dr. Zhang and colleagues reported on is one of the “novel” endovascular CHIMPS methods for aortic arch repair – CHIMPS meaning chimneys, periscopes, snorkels, and sandwiches (J Thorac Cardiovasc Surg. 2016;152:958-9). But they noted that one of the ongoing challenges with these types of parallel grafts is the gutter leaks that occur between the sandwich grafts.

The commentators noted that CHIMPS procedures are easier alternatives to using spiral branch graft stents for the thoracoabdominal aorta or direct-connecting branch stems from an aortic stent in the arch, but they added, “An important caveat is that the blood supply maintenance and long-term durability may not be adequate.”

The patient Dr. Zhang and colleagues reported on “is young and will need a durable operation,” Dr. Svensson, Dr. Eagleton, and Dr. Roselli said. “Unfortunately, in our experience over time we have observed that these CHIMPS procedures tend to break down and leak into the arch, including the arch actually rupturing,” they said. These patients will need “intensive” monitoring. What’s more, patients with Marfan syndrome are prone to aneurysm formation “and are not good candidates for stenting,” the commentators said.

“Nevertheless, further engineering iterations of CHIMPS may address the problem with gutter leaks and become an alternative to the elephant trunk procedure for those patients who are at particularly high risk,” the commentators said.

Dr. Svensson disclosed he holds a patent with potential royalties for an aortic valve and aortic root stent graft with connecting branch grafts to the coronary ostia. Dr. Roselli is a consultant and investigator for Bolton, Gore, and Medtronic. Dr. Eagleton has no relationships to disclose.


 

FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY

Traditional open repair for type A aortic dissection in patients with Marfan syndrome and a previous cardiovascular surgery carries a high risk of morbidity and mortality, but a team of surgeons from China have reported on a hybrid technique that combines open and endovascular approaches to repair type A dissection in a patient with Marfan syndrome.

They reported on a 33-year-old male with Marfan syndrome (MFS) who had elective aortic root and mechanical valve replacement 10 years earlier. Three days of persistent chest and back pain caused the patient to go to the emergency department, where computed tomography angiography (CTA) confirmed a type A aortic dissection from the distal ascending aorta to the iliac arteries and involving the proximal innominate artery and left common carotid artery (LCCA).

Because the patient refused another open surgery, Dr. Zhang and colleagues executed their hybrid approach, the first step of which was to create an LCCA-left axillar artery bypass with a 6-mm Gore-Tex graft (W.L. Gore & Associates). After they led the graft through the costoclavicular passage, they introduced the first (distal) thoracic stent (Valiant Captivia, Medtronic) from the right femoral artery and deployed it at the proximal descending aorta. They then inserted the second (proximal) thoracic stent graft into the previous ascending synthetic graft.

Next, they delivered the chimney grafts, two Fluency Plus covered stents (Bard Peripheral Vascular), from the right brachial and innominate artery into the ascending graft. Then they delivered two more Fluency grafts from the LCCA into the endolumen of the first (distal) thoracic stent graft.

After they deployed the second (proximal) thoracic stent graft, they deployed the precisely positioned stent grafts from the innominate artery and the LCCA, sandwiching the covered stents for the LCCA between the two thoracic stent grafts. They then occluded the left subclavian artery with a 10-mm double-disk vascular occlude.

Upon angiography at completion, Dr. Zhang and coauthors found an endoleak from the overlap zones between the two thoracic stent grafts.

However, the patient’s postoperative course was uneventful, and CTA 5 days after surgery showed complete sealing of the primary entry tear with patent chimney and sandwich grafts. The patient remained symptom-free at 30 days, when CTA again confirmed patency of the supra-arch grafts.

Dr. Zhang and coauthors acknowledge that carotid-to-carotid bypass could have been an alternative in order to use fewer stent grafts and to reduce the risk of endoleaks in this case, but they opted for this approach because of the dissection of the proximal innominate artery and LCCA and their concern of the long-term patency of a carotid-to-carotid bypass. “To our knowledge, this is the first reported case of a hybrid treatment for new-onset, type A aortic dissection in patients with MFS with a previous Bentall procedure,” Dr. Zhang and coauthors said. “Although further staged repairs are required in our case, this endovascular technique could be an effective and life-saving treatment option for the high-risk repeated surgical patients with MFS.”

Dr. Zhang and coauthors had no financial relationships to disclose.

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