Ann Thorac Surg 1998;65:241
© 1998 The Society of Thoracic Surgeons
Case Reports
Repair of Ruptured Anastomotic Aneurysm: Elephant Trunk Technique After Endovascular Covered Stents
Masahiko Ezure, MD,
Yutaka Kotsuka, MD,
Akira Furuse, MD,
Motohiro Kawauchi, MD,
Tadasu Kohno, MD,
Hiroshi Kubota, MD
Department of Cardiothoracic Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan
Accepted for publication August 12, 1997.
Dr Ezure, Department of Cardiothoracic Surgery, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113, Japan.
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Abstract
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Endovascular covered stents were successfully applied to temporarily halt hemoptysis and postpone surgical intervention in a 69-year-old man with a ruptured anastomotic false aneurysm of the distal aortic arch. Surgical graft implantation was performed successfully by the elephant trunk technique 14 days after the endovascular stent-grafting, at which time aspiration pneumonia had subsided.
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Introduction
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Postoperative pulmonary complications are a major problem in cases of thoracic aortic aneurysm that has ruptured into the lung. We applied endovascular covered stents in a patient with aspiration pneumonia due to rupture of an anastomotic aneurysm in the distal aortic arch, and later successfully operated by the elephant trunk technique.
A 69-year-old man came to the hospital as an emergency admission because of intermittent hemoptysis. He had undergone patch reconstruction for a ruptured tuberculous aneurysm of the distal aortic arch through a left thoracotomy 18 months previously. This case was previously reported by Ohtsuka and associates in this journal [1]. Chest roentgenography revealed a 5 x 4-cm aneurysmal shadow on the left side of the aortic arch associated with massive infiltration shadows in both lungs. A computed tomographic scan revealed a saccular aortic aneurysm just distal to the origin of the left subclavian artery, coinciding with the site of the previous aortic aneurysm (Fig 1A).
He experienced massive hemoptysis, and for a time went into shock. However, given the diagnosis of recurrent rupture of an aneurysm of the distal aortic arch, we considered it difficult to put this patient on cardiopulmonary bypass because of severe aspiration pneumonia, and therefore decided to insert endovascular covered stents.
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(A) Contrast-enhanced computed tomographic scan demonstrating a saccular aneurysm in the distal arch. (B) Postoperative computed tomographic scan showing thrombosis of the aortic aneurysm.
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The procedure was performed through the right femoral artery under local anesthesia. An 18F long sheath (VSSW-18.0-38-80; William Cook Europe, Denmark) was positioned in the aorta such that its tip came to rest distal to the left subclavian artery. The stent/graft was a thin-walled woven Dacron graft sewn onto a two-segment Z stent (GZV40-50; William Cook Europe). Each segment of the stent was 40 mm in diameter and 50 mm long. A stent-graft introduced through the sheath was positioned too far distally to cover the mouth of the false aneurysm, possibly due to blood flow pushing it caudad as the sheath was withdrawn or excessive friction within the sheath resulting in inadvertent distal migration of the entire apparatus. The second stent-graft, three fourths the length of the initial one, was introduced proximal to the first, and the two stent-grafts partially overlapped. When aortography confirmed that together the two adequately covered the false aneurysm, the procedure was concluded (Fig 2A).
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(A) Aortogram after stent-graft deployment showing that stent-grafts adequately cover the false aneurysm. Arrows show the proximal end of the stent-graft. (B) Postoperative aortogram showing no opacification of the aneurysm. Black arrows indicate the proximal end of the stent-graft, and white arrows show the distal end of the elephant trunk graft.
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Hemoptysis ceased immediately and the pulmonary infiltration subsided. However, the aneurysm was faintly visualized by aortography on day 8. Fresh bright red bloody sputum reappeared on day 13, necessitating an urgent operation on day 14. Through a median sternotomy, the operation was performed under circulatory arrest with cerebral perfusion. The proximal end of the stent-graft partially covered the origin of the left subclavian artery. However, it was not perfectly flat against the arterial wall, and a gap was seen in one area. Endoscopic examination revealed that the lesser curvature of the Z stent protruded into the lumen, and a fibrinous thrombus adhered to the inside of the graft. The proximal stent-graft was removed, and a 26-mm woven double velour Dacron graft (Hemashield; Meadox Medicals, Oakland, NJ) was inserted into the descending aorta. The distal portion of the woven Dacron graft was confirmed to overlap the inside of the distal stent-graft. The proximal end of the woven Dacron graft was then sutured intraluminally to the aorta between the left carotid artery and the left subclavian artery. The left subclavian artery was then ligated.
The postoperative course was uneventful. Aortography on postoperative day 36 showed that there was neither communication with the aneurysm nor irregularities in the wall of the woven Dacron graft and stent-graft (Fig 2B). Computed tomographic scanning showed that the aneurysm had been thrombosed (Fig 1B). The patient is currently being treated with antitubercular agents to prevent recurrence of the inflammation.
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Comment
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Our patient had undergone patch reconstruction of a ruptured tuberculous aneurysm and later had development of a pseudoaneurysm at the anastomotic site. The cause appeared to be either residual active inflammation of tuberculosis or fragility of the aortic wall resulting from the earlier inflammation [2].
Intravascular stent-grafting has been reported in patients with aneurysms of straight segments of the aorta, such as the descending aorta and the infrarenal abdominal aorta [3][4][5][6]. However, application to curved areas or segments containing side branches appears to be difficult. The aneurysm in our patient was just distal to the left subclavian artery, such that the proximal stent-graft was positioned to partially block the left subclavian artery, allowing complete coverage of the aneurysm. The stent-graft was not tightly apposed to the vessel lining, and communication between the vessel and the aneurysm persisted. However, the decrease in blood flow and pressure in the aneurysm produced by the stent-graft made it possible to control the hemoptysis and postpone the operation until the patient’s condition became relatively stable. During the operation, the distal stent-graft was left in the aorta, and the distal portion of the woven Dacron graft overlapped the stent-graft. This provided a sufficient fit between the vessel lining and the graft without sutures. There have also been reports of favorable results using endovascular stent-grafting to treat aneurysms of the descending aorta after vascular reconstruction by the elephant trunk technique [7]. Despite the stent and graft having been sutured at more than 20 points, the stent protruded into the lumen along the lesser curvature of the distal arch. Moreover, fibrinous thrombi were observed in the graft at the fixation sites, and on the protruding portion of the stent. So long as stent-grafts like the present ones are used in a curved portion of the aorta, fibrinous thrombi will inevitably develop at this location.
Although the stent/grafts currently available need further improvement, they may be used for patients in whom the risk of direct surgical intervention is extremely high.
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References
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- Ohtsuka T, Kotsuka Y, Yagyu K, Furuse A, Oka T Tuberculous pseudoaneurysm of the thoracic aorta. Ann Thorac Surg 1996;62:1831-1834.[Abstract/Free Full Text]
- Vlini FI, Olfield RC, Thompson JR, et al. Tuberculosis of the aorta. JAMA 1962;181:78-83.
- Kato M, Ohnishi K, Kaneko M, et al. Development of an expandable intra-aortic prosthesis for experimental aortic dissection. ASAIO J 1993;39:M758-M761.[Medline]
- Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729-1734.[Abstract/Free Full Text]
- Kato M, Matsuda T, Kaneko M, et al. Experimental assessment of newly devised transcatheter stent-graft for aortic dissection. Ann Thorac Surg 1995;59:908-915.[Abstract/Free Full Text]
- Mitchell RS, Dake MD, Semba CP, et al. Endovascular stent-graft repair of thoracic aortic aneurysms. J Thorac Cardiovasc Surg 1996;111:1054-1062.[Abstract/Free Full Text]
- Fann JI, Dake MD, Semba CP, Liddell RP, Pfeffer TA, Miller DC Endovascular stent-grafting after arch aneurysm repair using the elephant trunk. Ann Thorac Surg 1995;60:1102-1105.[Abstract/Free Full Text]
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Abstract
Introduction
