Ann Thorac Surg 1998;66:256-258
© 1998 The Society of Thoracic Surgeons
Original articles: general thoracic
Endoscopic placement of stents in aneurysms of the descending thoracic aorta
J. Honório Palma, MDa,
Antonio C. Carvalho, MDb,
Enio Buffolo, MDa,
Dirceu R. Almeida, MDb,
Walter J. Gomes, MDa,
Luiz A. Brasil, MDa
a Division of Cardiovascular Surgery, Escola Paulista de Medicina, São Paulo, Brazil
b Division of Cardiology, Escola Paulista de Medicina, São Paulo, Brazil
Accepted for publication February 2, 1998.
Address reprint requests to Dr Palma, Rua Borges Lagoa, 783, 5th Fl, São Paulo, SP, Brazil
e-mail: (jhpalma.dcir{at}epm.br)
 |
Abstract
|
|---|
This is a case of a patient with two saccular aneurysms in the descending aorta. Two self-expanding stents were inserted through an opening in the aortic arch, guided by the use of an Olympus endoscope, under profound hypothermia and total circulatory arrest. The bloodless field made possible the identification of the main thoracic branches, facilitating the positioning and deployment of both stents. Immediate postoperative recovery was excellent.
|
Introduction
|
|---|
Angioscopy was used for the first time in the mid-1980s; now it is used routinely and plays an important role in the treatment of diseases of the peripheral aorta. Endoscopic visualization of the aorta was initially related in 1957 by Brock [1], who used a rigid endoscope in the arch of the aorta to describe the vessels of the base during an intervention on the aortic valve.
The introduction in 1988 of the elephant trunk technique [2] for treatment of acute dissections of the descending aorta (type B) permitted substantial experience to be gained with this technique (73 cases) and established that it demanded inspection of the prosthesis in the operating room during circulatory arrest to avoid poor positioning or twisting of the graft. We herein present a case of two descending thoracic aortic aneurysms treated by autoexpandable stents placed with the aid of endoscopic techniques under deep hypothermic circulatory arrest.
The stent developed in our institution is composed of steel wires forming a tubular structure covered with Dacron material (Braille Biomedical, Rio Preto, Brazil). These cylinders composed of "zig-zag" steel wires give high resistance to radial compression, having the "memory" capacity to return to the diameter of its original construction once deployed. The prostheses are carefully compressed and inserted into a 22F-diameter catheter. Simple mobilization of the outer layer permits release of the self-expanding device, in a maneuver similar to commercially available kits.
This stent was previously tested in animals and in fresh cadaveric aortas with an Olympus EVS-100 adult gastrointestinal endoscope (Olympus, Osaka, Japan). During these experiments it was recognized that several branches of the aorta could be identified with precision (Fig 1).
View larger version (57K):
[in this window]
[in a new window]
|
Fig 1. Identification, in cadaveric aorta, of the renal (R) branches and superior mesenteric artery (SMA) (A) and the bifurcation of the abdominal aorta (AA) in the iliac region (B).
|
|
After suffering chest pain, a 67-year-old man was hospitalized with a diagnosis of aneurysmal dilatation of the thoracic aorta, beginning after the left subclavian artery. There was a second smaller dilatation in the distal thoracic aorta, delineated by aortography. The decision was made to treat the patient by stent deployment under endoscopic vision.
Under deep hypothermic circulatory arrest, an incision was made in the transverse arch and aortoscopic visualization of the descending thoracic aorta was achieved with an Olympus gastrointestinal endoscope.
At this point the patient was placed in an inclined position. A suction catheter was placed in the left iliac artery to remove blood from the lumen and permit a dry view of the aorta. A thorough examination of the aorta was possible from the arch to the femoral vessels. Thrombus formation was identified in both saccular aneurysms of the thoracic aorta.
Two ethylene oxide sterilized stents, custom made according to computed tomographic and aortographic findings, were deployed individually with direct endoscopic vision. First, a 6-cm-long stent (2.8 cm in diameter) was placed in the most distal aneurysm. A second 12-cm stent was deployed in the proximal aneurysm, beginning just after the left subclavian artery. The Dacron of this stent was sutured just distal to this artery with a running 4-0 Prolene (Ethicon, Somerville, NJ) suture. After deployment of both stents without complications, their position was confirmed by a final endoscopic visualization of the thoracic aorta. Total circulatory arrest lasted 32 minutes.
The patient’s 2-day postoperative stay in the intensive care unit was uneventful. A chest roentgenogram done on the fourth day demonstrated the stents positioned exactly where the aneurysms were previously located (Fig 2). There were no signs of hemolysis.
View larger version (77K):
[in this window]
[in a new window]
|
Fig 2. (A) Preoperative chest roentgenogram of the patient, demonstrating a large saccular aneurysm at the initial portion of the descending thoracic aorta, as well as a second smaller aneurysm in the median portion of the thoracic aorta. (B) Postoperative radiograph demonstrating the proximal and distal stents to be adequately placed.
|
|
|
Comment
|
|---|
Endoscopy of the vascular system was used initially as an experimental procedure and in recent years has evolved into a diagnostic technique and sophisticated therapy [3, 4]. The major limitation of angioscopy of vessels, without any doubt, is the large volume of blood within, which hinders adequate visualization. Use of total circulatory arrest under conditions of profound hypothermia, as proposed in this work, resolved part of the problem.
Since 1969, aneurysms of the abdominal aorta have been treated with stents deployed percutaneously [5]. Stents also have been used to treat aneurysms and dissection of the aorta [6, 7] and complications of aortic dissection [8].
Our current research and clinical work on endoscopic stent placement under deep hypothermic circulatory arrest offers a promising perspective of the technique to treat a variety of pathologic conditions of the aorta in the future. This technique will facilitate the management of complex cases, probably with low morbidity and mortality.
|
References
|
|---|
- Brock R.C. Surgical treatment of aortic stenosis. Br Med J 1957;1:1019-1028.[Medline]
- Palma J.H., Almeida D.R., Carvalho A.C., Andrade J.C., Buffolo E. Surgical treatment of acute type B aortic dissection using an endoprosthesis (elephant trunk). Ann Thorac Surg 1997;63:1081-1084.[Abstract/Free Full Text]
- Vollmar J.B., Storz L.W. Vascular endoscopy: possibilities and limits of its clinical application. Surg Clin North Am 1974;54:111-122.[Medline]
- Lee G., Ikeda R.M., Dwyer R.M. Feasibility of intravascular laser irradiation for in vivo visualization and therapy of cardiocirculatory diseases. Am Heart J 1982;103:1076-1077.[Medline]
- Dotter C.T. Transluminally placed coilspring endarterial tube grafts: long term patency in canine popliteal artery. Invest Radiol 1969;4:329-332.[Medline]
- Dake M.D., Miller D.C., Semba C.P., Mitchell R., Walker P.J., Liddel R.P. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysm. N Engl J Med 1994;331:1729-1734.[Abstract/Free Full Text]
- Marin M.L., Veith F.J., Panetta F., et al. Transluminally placed endovascular stent-graft repair for arterial trauma. J Vasc Surg 1994;20:466-473.[Medline]
- Slonim S.M., Nyman U., Semba C.P., Miller D.C., Mitchell S., Dake M.D. Aortic dissection: percutaneous management of ischemic complications with endovascular stents and balloon fenestration. J Vasc Surg 1996;23:242-253.
This article has been cited by other articles:
|
|
|
|
 
M. Karck and H. Kamiya
Progress of the treatment for extended aortic aneurysms; is the frozen elephant trunk technique the next standard in the treatment of complex aortic disease including the arch?
Eur. J. Cardiothorac. Surg.,
June 1, 2008;
33(6):
1007 - 1013.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
