Echocardiography-assisted surgery in transaortic endovascular stent grafting: Role of transesophageal echocardiography

Objective: Transesophageal echocardiography was applied to visualizing endovascular procedures during transaortic stent grafting for aneurysm and dissection at the distal arch, and the use of transesophageal echocardiography was evaluated. Methods: The 16 consecutive patients (13 with aneurysms and 3 with dissections) were examined. Transesophageal echocardiography was used for (1) determining graft size, (2) guiding placement of the catheter in the descending aorta at an appropriate position without intimal damage, (3) guiding graft tailoring with a balloon catheter, and (4) examining the results after the procedures. Results:Visualization was disturbed in one patient who had undergone a previous operation. The graft size was appropriate, except in one patient as a result of underestimation. Transesophageal echocardiography was helpful for navigating the graft placement and tailoring without intimal damage. We tried to keep a distance from the diaphragm of 9 cm and an attachment portion of 4 cm. In one patient the graft was placed too distally (7 cm from the diaphragm) to cover the thick atheromatous plaque with the graft. The patient had paraplegia. Transesophageal echocardiographic assessment of endoleak and thromboexclusion was identical to that of postoperative computed tomography or angiography, with a sensitivity of 100% (1/1) and a specificity of 100% (13/13). Leakage at the proximal suture and graft kinking were found in 3 patients. Successful thromboexclusion by transesophageal echocardiographic assessment (13 patients) was predictive of subsequent regression of aneurysm and dissection in the midterm follow-up period: there was complete and partial regression in 5 and 8 patients, respectively. Conclusion: Transesophageal echocardiography enables echocardiography-assisted operations with secure step-by-step endoluminal procedures and immediate intraoperative assessment, which is predictive of the postoperative results.