Ann Thorac Surg 2002;73:956-958
© 2002 The Society of Thoracic Surgeons
Case report
Successful stent-grafting for perforation of the thoracic aorta by an intraaortic balloon pump
Victor Bautista-Hernández, MDa,
Javier Moya, MDa,
Jorge Martinell, MD*a,
Maria Luz Polo, MD,a,
Julián Fraile, MD, PhDa
a Cardiovascular Surgery Service, Jiménez Díiaz Foundation, Madrid, Spain
Accepted for publication June 28, 2001.
* Address reprint requests to Dr Martinell, Servicio de Cirugíia Cardiovascular, Fundación Jiménez Díaz, Av Reyes Católicos 2, 28040 Madrid, Spain
e-mail: jmartinell{at}fjd.es
 |
Abstract
|
|---|
Vascular complications associated with intraaortic balloon pump placement are quite common and predominantly related to femoral or iliac damage. Iatrogenic injury of the thoracic aorta is less usual and often fatal. Surgery for the lesions of the descending thoracic aorta still has a relatively high morbidity and mortality. Endovascular covered stent-graft prostheses have become a less invasive therapeutic approach to lesions of the thoracic aorta, especially in patients with high surgical risk. We describe a case of perforation of the thoracic aorta caused by an intraaortic balloon pump. The injury was confirmed by aortography and successfully repaired by implantation of an endovascular stent-graft via the left common iliac artery.
|
Introduction
|
|---|
The intraaortic balloon pump (IABP) is the mechanical circulatory assist device most commonly inserted for perioperative cardiac failure [1]. Although the incidence of IABP-related complications has been markedly reduced by the use of percutaneus insertion [2] and of guided-wire central lumen balloons with reduced catheter sizes [1], they are still frequent, with reported incidence rates of approximately 25% [3]. The most common complications are limb ischemia and local hematoma or hemorrhage. Aortic injury is reported less (0% to 4%) and is usually limited to the abdominal aorta [3]. Laceration and perforation of the thoracic aorta, although described, are extremely rare. The routine therapeutic approach to this condition is surgical, with placement of a graft in the involved segment. Surgery for distal thoracic aortic pathology is still difficult due to its high morbidity and mortality [4]. Current management of the descending thoracic aorta with endovascular covered stent-graft prostheses is receiving increasing attention as a less invasive alternative to major thoracic surgery [5]. Stent-graft prostheses have been used to treat aneurysms, dissections, and acute rupture of the descending thoracic aorta with good clinical results [4–6]. This new method allows an entire thoracic aortic repair in less than 60 minutes, sparing the use of a thoracotomy with generally shorter recovery time and lesser hospitalization costs [6].
In July 2000, a 48-year-old man with unstable angina and an inferior myocardial infarction was admitted to our hospital. A preoperative catheterization of the heart showed severe left main stem coronary artery disease with intracoronary thrombus, and severe triple-vessel disease with normal left ventricular function. Via midsternotomy, emergency coronary bypass grafting surgery was achieved with the left saphenous vein to the left anterior descending artery, two branches of the left circumflex artery, and the right coronary artery. The left internal thoracic artery was not used, although dissected, because of the scarce flow and caliber. The left pleural space was entered. Extracorporeal circulation was established with aortic cannulation through the ascending aorta and venous drainage on the right atrium. The patient was operated on in moderate hypothermia (28°C to 32°C). Topical saline solution and cold crystalloid potassium cardioplegia through the aortic root were used for myocardial protection. Aortic cross-clamping and cardiopulmonary bypass time were 115 and 160 minutes, respectively. After declamping, the patient started with hypotension and electrocardiographic changes despite pharmacologic support. A perioperative IABP (Narrow Flex, Arrow International, Everett, WA) was implanted percutaneously using the standard Seldinger technique through the right femoral artery. No resistance was encountered while passing the catheter. Counterpulsation was effective and, after the operation, the patient, hemodynamically stable, could be transfered to the intensive care unit.
A chest roentgenogram, taken for checking the IABP location, showed malposition of the catheter in the descending thoracic aorta. Pleural spaces were free from liquid. IABP was then advanced for correct placement just below the left subclavian artery. Shortly after, the patient started with progressive hypotension and increasing bleeding rate. A second chest roentgenogram and an enhanced computed tomography scan revealed massive left pleural effusion. The patient was taken back to surgery for excessive bleeding. At reoperation, while the pericardial cavity was relatively free from blood and clots, the left pleural space had more than 2 liters of blood and a posterior mediastinal periaortic hematoma. No active bleeding point was evident at surgery despite conscientious revision. Aortography was subsequently performed showing extravasation of contrast medium from the descending thoracic aorta to the left pleural space and a large hematoma in the posterior mediastinum (Fig 1).
Morphometric measurements showed a diameter of the thoracic aorta at the point of perforation of 20 mm. A self-expanding endovascular covered stent-graft prosthesis (Aneurx, Medtronic, Minneapolis, MN) consisting of a circumferential nitinol stent (95-mm length and 26-mm width) and covered on its exterior with a Gore-Tex (W. L. Gore & Assoc, Flagstaff, AZ) graft was considered for this patient. The transfemoral approach was unsuccessful due to an insufficient iliofemoral diameter. After retroperitoneal exposure, and via the left iliac artery, a curved polytetrafluoroethylene (Teflon, Impra Inc, subsidiary of L.R. Bard, Tempe, AZ) 21F delivery sheet was then fluoroscopically guided (BV 25, Philips, Eindohoven, The Netherlands) to the descending thoracic aorta and delivered in the optimal position. The patient afterwards underwent a third-look surgery after the stent-graft prostheses placement for revision, with blood and clot removal of his left chest and transferred back to the intensive care unit.
View larger version (154K):
[in this window]
[in a new window]
|
Fig 1. Preimplantation aortic angiogram demonstrating extravasation of contrast from the descending thoracic aorta to the left pleural space and a large hematoma in the mediastinum (large arrowheads). Note the aortocoronary grafts (small arrowheads).
|
|
A computed tomographic scan and a chest roentgenogram performed 7 days after surgery confirmed adequate stent-graft prostheses placement, closing the perforation and the dissecting lumen (Fig 2).
Endovascular leakage or progression of the dissection were not confirmed. The patient recovered progressively thereafter developing a postimplantation syndrome with mild leukocytosis, elevated levels of C-reactive protein, and moderately elevated body temperature. Finally, he was discharged from our hospital 34 days after the operation without any more complications. Six months after discharge, the patient is asymptomatic, free of angina, and a magnetic resonance study showed adequate placement of the stent-graft prostheses without signs of endoleakage and with the false lumen partially thrombosed.
View larger version (123K):
[in this window]
[in a new window]
|
Fig 2. Postimplantation lateral chest roentgenogram showing the endovascular stent-graft prostheses placement (arrowheads) in the descending thoracic aorta.
|
|
|
Comment
|
|---|
Counterpulsation is a widely accepted therapy for ischemic myocardial dysfunction refractory to pharmacologic interventions [2]. IABP-related complications are relatively common, but injury of the thoracic aorta is very rare. Intimal damage done at the time of insertion or by further manipulations can be responsible for perforations and acute descending thoracic dissections; these can be serious and eventually lethal complications, if not promptly recognized and adequately treated. In our patient, perforation and dissection of the thoracic aorta was followed by a mediastinal hematoma, significant bleeding, and hemodynamic instability. Management of this condition remains a difficult clinical dilemma. In these situations, endovascular stent-graft prostheses represent an alternative therapeutic approach providing two major advantages. First, they offer a less invasive and feasible alternative to standard surgical repair, reducing the risks associated with thoracotomy and surgical graft placement. Second, the use of a slightly oversized stent-graft prostheses could avoid primary (leakage) or secondary (reperfusion) failure of endoluminal treatment. This report confirms that early diagnosis and prompt treatment of iatrogenic injuries of the thoracic aorta can be successfully managed by endovascular stent-grafting techniques applied in a surgical suite with a pluridisciplinary approach and in a cooperative "stressing" atmosphere. The usage of slightly oversized prostheses in these cases can also improve the attachment of the graft to the aortic wall with a better sealing, minimizing the risks of endovascular leakage and false lumen reperfusion.
|
Acknowledgments
|
|---|
We thank Milagros Fulgencio, Purificación Díaz, Juan Moreno, and Gema Ocampos for their assistance in the preparation of this article.
|
References
|
|---|
-
Arafa O., Pedersen T., Svennevig J., et al. Vascular complications of the intraaortic balloon pump in patients undergoing open heart operations: 15-year experience. Ann Thorac Surg 1999;67:645-651.[Abstract/Free Full Text]
-
Harvey J., Goldstein J., McCabe J., et al. Complications of percutaneous intraaortic balloon pumping. Circulation 1981;64(Suppl 2):114.
-
Wolff T., Stultz P. Successful surgery for perforation of the thoracic aorta caused by the tip of an intra-aortic balloon pump. Eur J Cardiothorac Surg 1997;11:1176-1179.[Abstract]
-
Usui A., Ueda Y., Watanabe T., et al. Clinical results of implantation of an endovascular covered stent-graft via midsternotomy for distal aortic arch aneurysm. Cardiovasc Surg 2000;8:545-549.[Medline]
-
Nienaber C., Fattori R., Lund G., et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999;340:1539-1545.[Abstract/Free Full Text]
-
Semba C., Kato N., Kee S., et al. Acute rupture of the descending thoracic aorta: repair with use of endovascular stent-grafts. J Vascular Intervention Radiology 1997;8:337-342.
Top
Abstract
Introduction
