Extent III TAAA Sandwich Technique – Apprenticeship from Dr. McKinsey

I just had a week of sub-I at Mount Sinai West, where Dr. James Mickinsey practices. For those of you who don’t know, he is internationally known for treating complex aortic cases, and the primary reason I was so excited to extend my stay one more day in this hospital that I have to travel 40 minutes each way. Below is a description for a sandwich technique for an extent III TAAA case I scrubbed.

Patient is a 84 YO AAM who has been followed by Dr. MicKinsey for an extent III TAAA that was >5.5 cm and had ulcerative plaques. The method of repair was going to be so called “Sandwich technique”, where chimney graft for visceral arteries will be sandwiched by two aortic stent grafts (schematics shown below). This technique was designed to bypass the expensive, time consuming step of personally designing fenestrated/branched TEVAR graft for each patient with TAAA that needs visceral artery coverage, and allows off-the-shelf selection of stent grafts.

Schematic drawing of the repair. Top picture shows deployment of first thoracic stent graft and cannulation of celiac and SMA from bilateral brachial cutdown. Middle drawing shows the finished product after sandwiching the balloon expandable stents in celiac and SMA by another aortic stent graft at the distal end of the first one. Bottom drawing shows the cross section design of the aortic and chimney stents, as well as gutters.

RIght CFA, with less iliac tortuosity was accessed and dilated up to 22F for deployment of the first thoracic stent graft, and left CFA accessed with 5F sheath for aortogram. Usually, axillary arteries would be accessed with cutdowns to cannulate the visceral arteries and deploy the chimney stents. Due to a history of hemi-facial and hemi-torsal burn with prior skin grafts covering the left chest and axillary region, cutting down on the axillary would lead to future skin breakdown, so we performed bilateral brachial artery cutdowns instead. One setback for the brachial cutdown is that since the patient’s arms would be abducted and extended, rotating the C-arm to get lateral fluoro views would be difficult. We solved this problem by abducting patient’s arm minimally, giving just enough space for adequate rotation of the C-arm. This might not be possible for obese patients.

Bilateral CFA were accessed first. Aortogram was taken to assess the TAAA, access vessels and visceral branches. Right CFA with less tortuous iliac artery was chosen to be the route of deployment of the first thoracic stent. Bilateral brachial cutdowns were done (an attending at each side with Dr. McKinsey monitoring outside, a common set up of lineup in a complex aortic case here as I’ve heard). The celiac axis and SMA were cannulated from above, balloon expandable chimney stents were inserted and deployed at the same time, with the proximal ends above the upper border of thoracic stent graft. The second aortic stent graft was deployed, sandwiching the chimneys, and the whole system was dilated with CODA balloon, but carefully avoiding the origins of celiac and SMA. Completion angio showed no endoleak. Whether or not to cover the renals then deploying a third aortic stent graft for a second sandwich were discussed, but due to the elderly status of the patient and the extent of coverage possibly leading to spinal cord ischemia, we decided to call it a day.

What a wonderful case that shows how far vascular surgery has come. From open surgery 20 years ago to endovascular cases nowadays, the field of vascular surgery has truly evolved with respective to time and technological innovation. Dr. Frank Veith (surgeon who performed the first EVAR in the U.S.) said in his presidential address during SVS annual meeting a while ago that vascular surgery needs to evolve like Darwinism. Dr. McKinsey’s practice is not only fascinating and unparalleled, but also definitely a representation of Dr. Veith’s vision.

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