Ann Thorac Surg 2002;74:1685-1687
© 2002 The Society of Thoracic Surgeons
Case Report
Treatment of thoracoabdominal aneurysm with self-expandable aortic stent grafts
José Honório Palma, MDa*,
Fausto Miranda, MDb,
Amaury R. Gasques, MDd,
Claudia Maria Rodrigues Alves, MDc,
José Augusto Marcondes de Souza, MDc,
Enio Buffolo, MDa
a Department of Cardiovascular Surgery, São Paulo, Brazil
b Department of Vascular Surgery, São Paulo, Brazil
c Department of Cardiology, Medical School, São Paulo Federal University, , São Paulo, Brazil
d Aortic Institute, Santa Marina Hospital, São Paulo, Brazil
Accepted for publication July 15, 2002.
* Address reprint requests to Dr Palma, Cardiovascular Surgery Department, São Paulo Federal University, Rua Borges Lagoa 1080, 7 Andar –São Paulo, SP, Brazil 04038-031, USA.
e-mail: jhpalma.dcir{at}epm.br
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Abstract
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A 67-year-old man with a large thoracoabdominal aneurysm was treated utilizing the endovascular approach with multiple stent graft implantation. The proximal thoracic and distal abdominal necks of the aneurysm had favorable anatomy for insertion of multiple endovascular stents. The proximal end was located just distal to the left subclavian artery, and stents were placed to the region of the celiac axis. The infrarenal aneurysm was treated with a bifurcated stent graft to the iliac arteries. The patient has had a smooth post-stent insertion course and remains well after 3 months of follow-up.
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Introduction
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Advancements in diagnostic techniques have made detection of thoracoabdominal aortic aneurysm feasible. Most centers report an increase of 5% in the detection of suprarenal aneurysms. These are usually present in elderly patients with serious comorbidities (renal, pulmonary, cerebral, and cardiac) that pose a great challenge to the surgeon [1]. A thoracoabdominal incision is made, approaching the aneurysm through the retroperitoneum, mobilizing the visceral organs medially. In some cases, the surgeon utilizes cardiopulmonary bypass to perfuse the distal vessels, hoping to decrease the incidence of paraplegia [2].
The advent of the endovascular aortic prosthesis provides these patients with alternative therapy which hopes to decrease morbidity and mortality [3]. We describe a patient with an extensive thoracoabdominal aneurysm treated with placement of multiple endovascular stents in the thoracic and distal abdominal aorta, including a bifurcated stent to the iliac arteries.
A 67-year-old man presented to our institution with a large, asymptomatic thoracoabdominal aortic aneurysm. Computed tomographic scans performed over a period of time showed increased diameter of the abdominal aneurysm. The tortuous thoracic aorta had an aneurysm measuring 9 cm from its proximal third to 4 to 5 cm proximal to the celiac axis. The aorta between the celiac axis and renal arteries was of normal size. Distal to the renal arteries the aneurysm measured 13 cm extending into both iliac arteries. Because there was a proximal (3-cm diameter of aorta) and distal (2.4-cm diameter of the aorta) neck in the thoracic and distal aorta, we treated this patient with multiple endovascular stents (Fig 1A).
In the first step of this intervention and under general anesthesia, the right femoral artery was dissected, and five endovascular stents (9 cm each) were deployed distally to the left subclavian artery. The endovascular stents were intussucepted into each other covering the left subclavian artery and extending to the celiac axis. Follow-up transesophageal echocardiography and computed tomographic scan showed exclusion of the thoracic aneurysm by the endovascular stent.
Correction of the abdominal aortic aneurysm was done 2 weeks later. The patient was again anesthetized, and endovascular stents were placed distally to the renal arteries extending into both iliac arteries. Before discharge, computed tomography showed multiple stents (Fig 1B) and total exclusion of the thoracoabdominal aneurysm by the endovascular stents (Fig 2).
The endovascular stents were stainless steel covered with polyester (Braile Medical, Sao Jose do Rio Preto, Sao Paulo, Brazil). The cylinders are highly resistant to radial collapse and maintain their ability to return to their original diameter once deployed. The prostheses were compressed and inserted into a 20 F catheter. Length, diameter, and whether the stent was bifurcated was selected according to the extension and size of the diseased segment to be treated.
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Comment
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The surgical treatment of thoracoabdominal aneurysms poses a major challenge to the cardiothoracic surgeon, especially because the patients are usually elderly and have serious comorbidities. The development of endovascular prostheses has greatly improved the treatment of patients with aneuryms or dissection in the thoracic and abdominal aorta [4–6]. This is a major achievement in the therapy of these aneurysms, but it necessitates precise diagnostic investigations to determine the proximal and distal necks of the aneurysm, vessels involved in the aneurysm, and location of tears in aortic dissection. One of the major challenges is the risk of paraplegia in patients who undergo surgical treatment of these aneurysms. Short cross-clamp time, distal perfusion, hypothermia, and steroids are few of the strategies aimed at decreasing this risk [7].
The use of endovascular stents potentially could decrease the risk of paraplegia and serious morbidities associated with the surgical approach. Chuter and associates [8] developed a multibranched stent graft for thoracoabdominal aneurysm. The use of endovascular stents will have to undergo clinical investigation to determine whether they decrease the incidence of serious morbidities. Although the patient is doing well at 3 months follow-up, longer follow-up is needed to further delineate the beneficial effects of this new approach to a complex problem.
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References
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- Okita Y, Ando M, Minatoya K, Tagusari O, Kitamura S, Nakajima N, Takamoto S. Early and long-term results of surgery for aneurysms of the thoracic aorta in septuagenarians and octogenarians. Eur J Cardiothorac Surg 1999;16:317–23
- Svensson L.G., Crawford E., Hess K.R., Coselli J.S., Safi H.J. Experience with 1509 patients undergoing thorocoabdominal operations. J Vasc Surg 1993;17:357-370.[Medline]
- Parodi J.C. Endovascular repair of abdominal aortic aneurysms and other arterial lesions. J Vasc Surg 1995;21:549-557.[Medline]
- Dake M.D., Kato N., Michell R.S. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340(20):1546-1552.[Medline]
- Nienaber C.A., Fattori R., Lund G., et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999;340(20):1539-1545.[Medline]
- Palma J.H., Almeida D.R., Carvalho A.C., Andrade J.C.S., 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]
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Abstract
Introduction
