Ann Thorac Surg 2003;75:530-533
© 2003 The Society of Thoracic Surgeons
Original article: cardiovascular
Endoluminal repair of aneurysms associated with coarctation
Rachel E. Bell, FRCSa,
Peter R. Taylor, FRCSa*,
Marion Aukett, BS(Hons)a,
Christopher P. Young, FRCSb,
David R. Anderson, FRCSb,
John F. Reidy, FRCRc
a Department of General and Vascular Surgery, Guy’s and St. Thomas’ Hospital, London, United Kingdom
b Department of Cardiothoracic Surgery, Guy’s and St. Thomas’ Hospital, London, United Kingdom
c Department of Radiology, Guy’s and St. Thomas’ Hospital, London, United Kingdom
Accepted for publication August 21, 2002.
* Address reprint requests to Dr Taylor, Department of General and Vascular Surgery, Guy’s and St. Thomas’ Hospital, Lambeth Palace Rd, London, SE1 7EH, UK
e-mail: taylorvasc{at}aol.com
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Abstract
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BACKGROUND: Late aneurysm formation is a well-recognized complication of surgery for aortic coarctation. Open surgery to repair these aneurysms is associated with significant morbidity and mortality. Endoluminal repair is an attractive alternative to open surgery.
METHODS: Data were collected prospectively on consecutive patients who presented with aneurysms associated with coarctation
RESULTS: Between June 1999 and October 2001, 5 patients underwent elective endoluminal repair for coarctation aneurysms. All procedures were technically successful and no patients died. Four patients previously had open surgery to repair aortic coarctation, and 1 presented with an aneurysm associated with a previously unrecognized coarctation. The median follow-up was 7 months (range, 3 to 29 months), and to date, all aneurysms remain excluded.
CONCLUSIONS: Endoluminal repair is a promising alternative to redo open surgery for thoracic aneurysms associated with previous surgery for aortic coarctation. Long-term follow-up is required to assess the durability of the stent grafts.
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Introduction
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Coarctation of the aorta accounts for 3% to 5% of all congenital cardiac malformations [1]. Surgical techniques for coarctation repair include patch aortoplasty, left subclavian flap aortoplasty, and coarctectomy with end-to-end anastomosis or prosthetic interposition graft. Late aneurysm formation is a well-recognized complication of all these types of repair [1–6]. However, it is most commonly associated with synthetic patch angioplasty (5% to 51%), and the incidence of aneurysm formation increases with time [6–9]. Aneurysms associated with patch aortoplasty typically occur opposite to the synthetic patch and are localized to the proximal descending aorta. If left untreated, there is a high rate of rupture [7].
Traditionally, these aneurysms have required open surgery, which is associated with significant risk of recurrent laryngeal nerve paralysis (13.1% to 36%), phrenic nerve injury (5% to 6%), and death (13.8%) [7, 9]. Recently, endoluminal repair has been used to treat isolated descending thoracic aneurysms and distal arch aneurysms with good early results [10, 11]. There is one previous report describing endoluminal repair of an aneurysm associated with a previously unrecognized aortic coarctation in a man 23 years of age [12]. However, stenting has been used successfully to treat cases of recoarctation [13]. We describe five cases of successful endoluminal repair of aneurysms associated with coarctation.
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Patients and methods
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Five patients underwent endoluminal repair of coarctation aneurysms between June 1999 and October 2001 (Table 1).
All patients were treated electively. The group consisted of 4 women and 1 man. The median age was 31 (range, 21 to 77) years. Four out of 5 patients had previously had surgery for aortic coarctation (three patch aortoplasties, one left subclavian flap angioplasty). One patient (aged 71 years) developed an aneurysm distal to an unrecognized aortic coarctation.
Three out of 5 patients presented with respiratory complications. Patient 1 had a patch aortoplasty for repair of a coarctation at 3 months of age and required redo surgery at 12 years. She presented at 31 years of age with stridor and exertional dyspnoea due to compression of her left main bronchus by a 7-cm thoracic aneurysm (Fig 1).
In addition, she was complaining of chronic back pain, which was secondary to bone erosion caused by the aneurysm. Patient 2 had left subclavian aortoplasty at 2 months for repair of aortic coarctation and required revision at 6 months. She presented at 21 years of age with exertional dyspnoea and was found to have a 6-cm descending thoracic aneurysm. Patient 3 presented at 71 years of age with progressive dyspnoea. The initial plain chest radiograph showed collapse of the left lung as a consequence of compression of the left main bronchus by a 7-cm thoracic aneurysm. Further arteriography showed that she had developed a poststenotic dilatation from an unrecognized asymptomatic coarctation with a gradient of 27 to 30 mm Hg (Fig 2). Patient 4 had a patch aortoplasty at 5 years of age for repair of an aortic coarctation. She presented at 30 years of age with a 6-cm thoracic aneurysm discovered on magnetic resonance imaging of the chest after an episode of pneumonia (Fig 3).
Patient 5 had previously had Dacron patch aortoplasty for repair of a pseudocoarctation at 48 years of age. Subsequently, he had an aortic valve replacement and coronary artery bypass grafting at 69 years of age. He presented at 77 years of age with an asymptomatic 9-cm thoracic aneurysm.
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Fig 1. Arteriogram showing a thoracic aneurysm associated with previous coarctation repair before (a) and after (b) endoluminal repair.
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Fig 2. Arteriograms showing a previously unrecognized aortic coarctation with an associated aneurysm before (a) and after (b) endoluminal repair.
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Fig 3. Arteriogram showing a thoracic aneurysm associated with a previous patch aortoplasty for coarctation (left). The stent graft has covered the left subclavian artery (right).
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All patients had preoperative computed tomography scans and angiography with a measuring catheter. The procedures took place in the endovascular suite of the radiology department. The types of stent graft used were the Excluder (WL Gore and Associates, UK, Livingstone, Scotland) in 4 patients and the Zenith (William Cook, Europe, Bjaevershov, Denmark) in 1 patient. Devices were oversized by a minimum of 10% relative to the normal aorta at the fixation sites, with a minimum of 2 cm of normal aorta to seal the stent grafts at the landing zones. All devices were inserted through the common femoral artery, and patients were given 5,000 U of unfractionated heparin intravenously before insertion of the 22F to 24F delivery sheath. The device was introduced into the aortic arch over an extra stiff guidewire (Lunderquist; William Cook, Bjaevershov, Denmark), and deployed in the optimal position. Hypotension was not used in any patient. Two patients had the origin of the left subclavian artery deliberately covered in order to adequately secure the stent graft proximally. A postdeployment angiogram was performed to check the position of the stent graft and to identify endoleaks. The sheath was then removed and the femoral arteriotomy closed. The wound was closed with absorbable sutures. The procedure was performed under general anesthesia in 4 patients and regional anesthesia in 1. Patients were observed in recovery for 4 hours and were allowed to drink on return to the ward. Follow-up spiral computed tomography and plain chest radiograph were performed at 3, 6, and 12 months, and then annually thereafter.
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Results
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Stent deployment was technically successful in all 5 patients. No patients died. The median stent diameter and length was 26 mm and 12 cm, respectively (diameter range, 14 to 34 mm; length range, 9 to 27cm). In the patient with previously unrecognized coarctation, the gradient was 27 to 30 mm Hg prestenting, and fell to 7 to 14 mm Hg postprocedure. One patient required three stent grafts to exclude the aneurysm sac, which was associated with an aneurysm affecting most of the descending thoracic aorta. Neither of the patients who had the left subclavian artery covered required revascularization of the left arm. All 5 patients were discharged from hospital within 48 hours of the procedure. The median follow-up was 7 months (range, 3 to 29 months). To date, all aneurysms remain excluded, and there is no evidence of endoleaks or stent migration
One patient was readmitted 2 weeks after the procedure. He had previously had an aortic valve replacement and had received appropriate antibiotic prophylaxis. He developed spiking fevers and splinter hemorrhages. Despite a normal trans-esophageal echocardiogram (no valve vegetations) and no microbiological evidence of infection, he was treated empirically for subacute bacterial endocarditis. He is currently well 29 months postprocedure and is no longer on antibiotics.
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Comment
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Late aneurysm formation is a potentially fatal long-term complication of both coarctation repair and untreated subclinical coarctation. In one study of Dacron patch aortoplasty repair performed for coarctation, 10 patients out of a study group of 39 patients ruptured their aorta, of which, 6 died at a mean interval of 8 years [8]. Magnetic resonance imaging performed in 33 survivors showed that 20 had developed aneurysms. Rupture was associated with pregnancy in women. The most cost-effective method of following up patients who have undergone repair of a coarctation of the aorta has recently been evaluated [14]. A retrospective analysis of 84 patients suggested that although a chest radiograph was useful, but magnetic resonance imaging was the investigation of choice.
Unrecognized coarctation of the aorta is associated with aneurysm formation, and stent grafts have been used previously in a young patient [13].
Redo thoracic surgery in this group of patients is hazardous. Endoluminal repair appears to be a safe alternative to open surgery and avoids the risks of both recurrent laryngeal and phrenic nerve injury. Endovascular treatment of these aneurysms is straightforward, as they are usually localized to the proximal descending aorta. The procedure involves arterial access through the common femoral artery, and therefore, thoracotomy is unnecessary. The majority of aneurysms associated with coarctation can be treated with short stent grafts, and this reduces the potential risk of paraplegia [15]. It is also safe to cover the left subclavian artery without the need for revascularisation [11, 16].
Endovascular repair of an isolated thoracic aneurysm was first reported in 1988 [17]. Since then, there have been several reports of successful endoluminal repair of descending thoracic aneurysms, and the associated mortality and morbidity is a vast improvement on open surgery [11, 15–18]. It is technically possible to repair distal arch aneurysms endoluminally if carotid-carotid bypass is performed before stenting so the graft can be placed over the origin of the left common carotid artery. The Stanford group has the largest experience of endoluminal treatment of descending thoracic aneurysms. They treated 144 patients using a custom-made graft. Complete thrombosis of the aneurysm sac was achieved in 85% of patients, and the early mortality was 8%. Paraplegia occurred in 3% and stroke in 5%. [18] Recent series using commercially produced stent grafts have reported encouraging results [11, 19]. The Achilles heel of the infrarenal stent grafts is the durability of the devices. Stent graft failure has been reported with the early homemade thoracic devices, but as yet, we do not have long-term follow-up on the commercially manufactured grafts [10].
Our encouraging experience suggests that endoluminal repair is a useful alternative treatment to open surgical operation for aneurysms associated with coarctation of the aorta. However, the durability of stent grafts remains to be determined, and all patients require long-term follow-up with cross-sectional imaging.
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Acknowledgments
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Dr Bell is supported by a grant from the Charitable Foundation of Guy’s and St. Thomas’ Hospital.
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References
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- Nguyen D.M., Tsang J., Tchervenkov C.I. Aneurysm after subclavian flap angioplasty repair of coarctation of the aorta. Ann Thorac Surg 1999;68:1392-1394.[Abstract/Free Full Text]
- Kino K., Sano S., Sugawara E., et al. Late aneurysm after subclavian flap angioplasty for coarctation of the aorta. Ann Thorac Surg 1996;61:1262-1264.[Abstract/Free Full Text]
- Martin M.M., Beekman R.H., Rocchini A.P. Aortic aneurysm after subclavian aortoplasty repair of coarctation of the aorta. Am J Cardiol 1988;61:951-953.[Medline]
- Bergdahl L., Ljunquist A. Long term results after repair of coarctation of the aorta by patch grafting. J Thorac Cardiovasc Surg 1980;80:177-181.[Abstract]
- Fujita T., Fukushima N., Taketani S. Late aneurysm after bypass grafting for long aortic coarctation. Ann Thorac Surg 1996;62:1511-1513.[Abstract/Free Full Text]
- Bromberg B.I., Beekman R.H., Rocchini A.P. Aortic aneurysm after patch angioplasty repair of coarctation: a prospective analysis of prevalence, screening tests and risks. J Am Coll Cardiol 1989;14:734-741.[Abstract]
- Knyshov G.V., Sitar L.L., Glagola M.D., et al. Aortic aneurysms at the site of the repair coarctation of the aorta: a review of 48 patients. Ann Thorac Surg 1996;61:935-939.[Abstract/Free Full Text]
- Parks W.J., Ngo T.D., Plauth W.H., Jr, et al. Incidence of aneurysm formation after Dacron patch angioplasty repair for coarctation of the aorta: long term results and assessment utilizing magnetic resonance angiography with three dimensional surface rendering. J Am Coll Cardiol 1995;26:266-271.[Abstract]
- Ala-Kulju K., Heikkinen L. Aneurysm after patch graft aortoplasty for coarctation of the aorta: long term results of surgical management. Ann Thorac Surg 1989;47:853-856.[Abstract]
- Dake M.D., Miller D.C., Mitchell R.S., et al. The "first generation" of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta. J Thorac Cardiovasc Surg 1998;116:689-704.[Abstract/Free Full Text]
- Taylor P.R., Gaines P.A., McGuinness C.L., et al. Thoracic aortic stent grafts: early experience from two centers using commercially available devices. Eur J Vasc Endovasc Surg 2001;22:70-76.[Medline]
- John A., Gunn J., Bowes R.J., Gaines P.A., Hamm C.W. Interventional therapy of aortic isthmus stenosis with concomitant thoracic aortic aneurysm with a stent graft. Zeitschrift fur Kardiologie 2000;89:962-964.[Medline]
- Harrison D.A., McLauglin P.R., Lazzam C., Connelly M., Benson L.N. Endovascular stents in the management of coarctation of the aorta in the adolescent and adult: one year follow-up. Heart 2001;85:561-566.[Abstract/Free Full Text]
- Therrien J., Thorne S.A., Wright A., Kilner P.J., Somerville J. Repaired coarctation: a "cost-effective" approach to identify complications in adults. J Am Coll Cardiol 2000;35:997-1002.[Abstract/Free Full Text]
- Greenberg R., Resch T., Nyman U., et al. Endovascular repair of descending thoracic aneurysms: early experience with immediate-term follow-up. J Vasc Surg 2000;31:147-156.[Medline]
- Hausegger K.A., Oberwalder P., Tiesenhausen K., et al. Intentional left subclavian artery occlusion by thoracic aortic stent-grafts without surgical transposition. J Endovasc Ther 2001;8:472-476.[Medline]
- Volodos N.L., Kapovich I.P., Shekhanin V.E., et al. A case of distant transfemoral endoprosthesis of the thoracic artery using a self-fixing synthetic prosthesis in traumatic aneurysm. Grud Khirurgiia 1988;6:84-86.
- Dake MD. Endovascular treatment for thoracic aneurysms. In: Branchereau A and Jacobs M, eds. Surgical and endovascular treatment of aortic aneurysms. Futura Publishing Company, Inc: New York. 2000:27–34
- Grabenwöger M., Hutschala D., Ehrlich M.P., et al. Thoracic aneurysms: treatment with endovascular self-expandable stent grafts. Ann Thorac Surg 2000;69:441-445.[Abstract/Free Full Text]
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Abstract
Introduction
