Ann Thorac Surg 2004;77:1445-1447
© 2004 The Society of Thoracic Surgeons
Case report
New access to facilitate endovascular repair of descending aorta aneurysms
Carmine Minale, MDa*,
Pierluigi Cappiello, MDa,
Bruno Cimmino, MD,
Maurilio Di Natale, MDa
a Cardiology Department, Division of Cardiovascular Surgery, San Carlo Hospital–Potenza, Potenza, Italy
Accepted for publication May 20, 2003.
* Address reprint requests to Prof Dr Minale, Cardiology Department, Division of Cardiovascular Surgery, San Carlo Hospital–Potenza, Macchia Romana, I –85100 Potenza, Italy.
e-mail: caminale{at}ospedalesancarlo.it
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Abstract
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Coexisting arterial diseases and endoprosthesis to peripheral-vessel mismatch may impair conventional femoral access for endovascular treatment of descending aorta aneurysms. Furthermore, previous abdominal operations can make an optional aortic-iliac approach more difficult. We introduced a new minimally invasive access through the aortic arch, which completely avoids the aortic-iliac access and minimizes surgical trauma.
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Introduction
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The use of stent-graft has become an established method for endovascular treatment of thoracic aortic aneurysms. The advantages consist mainly in lower mortality and morbidity with respect to the conventional open repair. In the majority of patients, the deployment catheter is introduced through the femoral artery. In case of peripheral obstructive vascular disease, several ancillary techniques have been reported [1, 2] to facilitate access using the iliac artery, the abdominal aorta, and recently the common carotid and the axillary artery [3].
There are conditions, such as previous retroperitoneal operations, hostile abdomen, and endoprosthesis to peripheral-vessel along with supraortic arteries mismatch, which can limit the use of endovascular treatment.
For these rare cases, we suggest a new minimally invasive approach completely avoiding the aortic-iliac access as well as deployment catheter to peripheral vessel diameter mismatch.
A 77-year-old woman, who had suffered for several months with back pain, was admitted to our institution exhibiting signs of cachexia and general poor health. She had been on regular hemodialysis, after the repair of an aortic-iliac aneurysm 2 years prior, when her compensated renal failure further deteriorated. She had a moderate chronic obstructive pulmonary disease and generalized angiosclerosis. The thoracic computed tomographic scan and the angiographic examination revealed a 4-cm sacciform aneurysm of the middle part of the descending aorta (Fig 1).
Due to a favorable aneurysm anatomy, the patient was scheduled for endovascular therapy. The diameters of the y-graft branches used for the abdominal aneurysm repair were 8 mm. They were too small to allow the 22Fr (7.1 mm) deployment catheter of the 26-mm diameter stent-graft to be passed through without damage of the neointima. The optional retroperitoneal aortic access was avoided because of heavy scarring around the aortic prosthesis, and the fear of mobilizing neointima from the inner wall of the prosthesis.
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Fig 1. Angiogram of descending thoracic aorta before the operation. A typical sacciform aneurysm (4-cm diameter) is evident on the left side of the aorta.
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Under general endotracheal anesthesia, an access was created through a L-incision of the manubrium of the sternum with cross-section to the right in the second intercostal space (mini-sternotomy; Fig 2A).
The upper pericardium half was opened. A transesophageal echography was done during the procedure to localize the portion of the aortic arch free of intima debris. A sleeve of a 10-mm Dacron tube graft (DuPont Pharmaceuticals, Wilmington, DE) was sewn end-to-side to the ascending aorta without a partial excluding vascular clamp (Fig 2B). The stitches were passed through the entire thickness of the aortic wall before opening it. Thereafter, a 22Fr introducer of a 26-mm diameter Medtronic-Talent stent-graft (Medtronic B.V., Kerkrade, The Netherlands) was passed through the graft sleeve into the aortic arch by Seldinger technique. Under roentgenogram control, the stent-graft was deployed across the aneurysmatic portion of the aorta (Figs 3–5).
The graft sleeve was used to achieve hemostasis during the procedure with aid of a snare. After removal of the
introducer, the sleeve was sewn with a running suture adjacent to the aortic wall.
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Fig 2. (A) Access through an L-incision of the manubrium of the sternum with cross-section to the right in the second intercostal space (ICS) (mini-sternotomy). (B) A sleeve of a 10-mm Dacron tube (DuPont Pharmaceuticals, Wilmington, DE) sewn end-to-side to the ascending aorta without a partial excluding vascular clamp. The stitches are passed through the entire thickness of the aortic wall before opening it. A 22Fr introducer is passed through the graft sleeve into the aortic arch by Seldinger technique, with the aid of a snare to control hemostasis.
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Fig 4. The endoprosthesis has been fully deployed. The angioplasty balloon catheter introduced from the top adapt the collars of the prosthesis against the aortic wall.
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Fig 5. Angiogram of descending thoracic aorta at completion of the procedure. Complete exclusion of the aneurysm is evident.
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The patient was weaned off the respirator at the end of the procedure. There was no negative event and her conditions would have allowed her to be discharged the following day. However, due to a lack of autosufficiency and adequate home support, she remained in the hospital a few days longer. The computed tomographic scan before discharge revealed a complete exclusion of the aneurysm.
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Comment
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Endoprosthetic treatment of descending aorta aneurysms is becoming more and more frequent, particularly when dealing with poor risk patients. Unfortunately, due to the relatively large dimensions of the introducers available at the present time or the involvement of the peripheral arteries with occlusive disease, the conventional access through the groin cannot be used in all patients. There are different techniques to overcome these problems, which consist mainly in isolating the iliac arteries or even the abdominal aorta, and to deploy the device through these accesses [1, 2]. These options are not quite minimally invasive, particularly when dealing with previous retroperitoneal operations or hostile abdomen. Occasionally this maneuver is even impracticable. Attempts have also been made to introduce the endoprosthesis through the aortic arch by right axillary artery along with the carotid artery [3], depending on the individual anatomy of these vessels. These accesses have been used in isolated cases without evident complications [3]. Endovascular stent-grafting through the aortic arch for distal aortic arch aneurysms was already suggested [4, 5], but it was used only in connection with other open-heart procedures, or even with circulatory arrest. Previous experiences with introduction of intraortic balloon catheter for counterpulsation through the aortic arch in case of occlusive aorto-iliac disease [6] inspired us to utilize this access also for deployment of a stent-graft. There are neither limitations due to the catheter diameter, nor necessity to exclude, even partially, the aortic arch. In case of calcification or plaque on the arch wall, revealed by intraoperative transesophageal echography, the catheter can even be introduced through the distal portion of the arch to avoid embolization to the cerebral vessels. Despite the relative rigidity of the introduction system, we encountered no problem in passing the wire and the introducer itself through a 120-degree curve (Figs 4 and 5). Even though the condition of our patient was poor, the mini-sternotomy access caused minimal surgical stress so that she could be extubated at the end of the procedure in the operating room. Under these conditions an early discharge home can generally be anticipated.
Due to its relatively low morbidity and mortality, the stent-graft should be regarded as the first choice treatment method of descending aorta aneurysms. In case of difficulty deploying the stent-graft through the femoral or iliac arteries, or even through the abdominal aorta, the access through the aortic arch by a mini-sternotomy offers a good option to reach the objective.
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References
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- Yano O.J., Faries P.L., Morrissey N., Teodorescu V., Hollier L.H., Marin M.L. Ancillary techniques to facilitate endovascular repair of aortic aneurysms. J Vasc Surg 2001;34:69-75.[Medline]
- Macdonald S., Byrne D., Rogers P., Moss J.G., Edwards R.D. Common iliac artery access during endovascular aortic repair facilitated by transabdominal wall tunnel. J Endovasc Ther 2001;8:135-138.[Medline]
- Estes J.M., Halin N., Knoun M., Burch J., England M., Mackey W.C. The carotid artery as alternative access for endoluminal aortic aneurysm repair. J Vasc Surg 2001;33:650-653.[Medline]
- Orihashi K., Sueda T., Watari M., Okada K., Ishii O., Matsuura Y. Endovascular stent-grafting via the aortic arch for distal aortic arch aneurysm: an alternative to endovascular stent-grafting. Eur J Cardiothorac Surg 2001;20:973-978.[Abstract/Free Full Text]
- Sueda T., Watari M., Orihashi K., Shikata H., Matsuura Y. Endovascular stent-grafting via the aortic arch for distal arch aneurysm: an alternative of endovascular stent-grafting in a complicated case. Ann Thorac Cardiovasc Surg 1999;5:206-208.[Medline]
- Salerno T.A. Insertion of the intra-aortic balloon through the ascending aorta and its removal under local anesthesia. Can J Surg 1983;26:69.[Medline]
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Abstract
Introduction
