Ann Thorac Surg 2004;78:1075-1078
© 2004 The Society of Thoracic Surgeons
Case report
Open aortic surgical repair for left hemi-arch stent-graft failure
Vincenzo Rampoldi, MDa,
Santi Trimarchi, MDa,*,
Paolo Righini, MDa,
Valerio Tolva, MDa,
Luigi Inglese, MDb
a Department of Vascular Surgery, San Donato Milanese, Italy
b Cardiac Catheterization Laboratory, Istituto Policlinico San Donato, San Donato Milanese, Italy
Accepted for publication March 15, 2004.
* Address reprint requests to Dr Trimarchi, Istituto Policlinico San Donato, via Morandi 30, San Donato Milanese 20097, Italy
satrimarchi{at}yahoo.it
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Abstract
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A surgical technique of endovascular graft explant through an open aortic approach for left hemi-arch stent-graft failure is described. Between January and April 2003, we surgically treated 3 patients previously submitted for stent grafts for isthmic aortic diseases. Two patients had atherosclerotic aneurysm and 1 had a false lumen reperfusion of subacute intramural hematoma. At 6 to 8 months computed tomographic scan follow-ups on all patients showed a rapid enlargement of aortic diameters due to type I endoleaks. The presence of an uncovered proximal stent in the parasubclavian aorta did not allow a simple aortic cross clamping; therefore we performed an open aortic procedure through a left posterolateral thoracotomy, using femoro-femoral bypass and mild hypothermic circulatory arrest. Selective antegrade cerebral perfusion was started within 3 to 5 minutes from aortotomy and graft removal. Left hemi-arch and descending thoracic aortic replacement was then performed with continuous cerebral perfusion. No surgical mortality was observed. Postoperative course was uneventful for neurologic, cardiac, respiratory, and renal complications. The 3-month follow-ups were event free. This approach, associated with rapid stent-graft explant and selective cerebral antegrade perfusion, appears to be a safe and effective surgical strategy for treating this new aortic pathology.
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Introduction
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Management of patients affected by thoracic aortic pathologies is still being debated by physicians involved in the therapy of degenerative aneurysms and acute or chronic aortic dissections. Aortic stent-graft implantation represents an alternative to conventional surgical procedures for atherosclerotic thoracic aortic aneurysms [1] and complicated acute aortic dissections in which the primary entry is located in the descending thoracic aorta [2]. However, the endovascular graft is often difficult to deploy and to adapt into the branched and curved left hemi-arch, and a significant incidence of surgical conversion or treatment of long-term endovascular failures have been shown [3]. We believe there have been no previous reports on the surgical experience of thoracic stent-graft explants. We describe the surgical treatment and short-term results of thoracic aortic stent-graft failure.
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Case reports
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Between January and April 2003, we observed 3 patients previously submitted for stent grafts for descending thoracic aortic aneurysms and false lumen reperfusions in subacute intramural hematoma. All cases presented rapid enlargement of aortic diameters related to type I endoleaks at 6- to 8-month follow-up computed tomographic scans.
Patient 1
A 42-year-old man who was affected by hypertension and thrombocytosis had a thoracic stent graft with left subclavian artery coverage for an 8-cm isthmic aortic aneurysm involving the proximal segment of the descending aorta. A 3-month transesophageal echocardiogram showed enlargement of the aneurysmal sac without evidence of color-flow enhancement outside the stent. An angiogram did not show any type of endoleak. Eight months later the patient complained of dysphagia and a computed tomographic scan showed an increase aortic diameter to 11 cm with contrast in the peri-graft space. An angiogram showed a type I endoleak.
Patient 2
A 75-year-old woman was admitted for an endovascular thoracic stent graft from the isthmus to the diaphragm for reperfusion of an intramural hematoma 2 weeks after the onset of symptoms. The primary entry site was located in the middle tract of the descending thoracic aorta. The aortic diameter at this level was 3.9 cm. This patient was taking dicumarol, because she had undergone a previous composite mechanical aortic valve graft. At her 6-month follow-up computed tomographic scan, a rapid enlargement of the aorta was observed with a maximum diameter of 7 cm. A magnetic resonance image evidenced the presence of a type I endoleak.
Patient 3
A 48-year-old man was operated for a composite valve-tube graft and aortic arch replacement for acute type A dissection. Two years later he was treated with an endoluminal coverage of a 6-cm postdissecting thoracic aortic dilatation involving the isthmus. This patient was also taking oral anticoagulant therapy. A perioperative angiogram had shown a residual type I endoleak that had been conservatively managed. At 3-month and 6-month follow-up computed tomographic scans, an increase of 2 cm in aortic isthmus caliber was detected (Fig 1).
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Fig 1. Computed tomographic scans showing type I endoleak and rapid increase of aortic diameters after thoracic stent graft.
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Technique
The thorax was entered through the left posterolateral thoracotomy in the 4th and 7th intercostal spaces. Extracorporeal circulation was established with femoro-femoral cannulation, venting from the left superior pulmonary vein. Mild hypothermic circulatory arrest was initiated at 26°C of bladder temperature. The aortic isthmus was opened with a longitudinal aortotomy and the proximal neck of the endograft was carefully removed after incision of the uncovered proximal stent (bare spring) using a wire lateral cutting forceps (Fig 2A, 2B, 2C ). Selective cannulation of the innominate artery and the left common carotid artery (LCA) were done using a 15 French cannula (Chase Medical, Texas) with a mean flow rate of 600 mL/min. Selective antegrade cerebral perfusion (SCP) was started within 3 to 5 minutes from circulatory arrest (Fig 2D). The left subclavian artery was occluded with a 5 French Fogarty catheter (Edwards Lifesciences, Irvine, CA) to avoid steel phenomenon in the circle of Willis. Then a complete explant of the stent graft was accomplished after opening the aorta until the endograft distal neck. The supradiaphragmatic thoracic aorta was cross clamped to perfuse visceral and intercostal vessels through the arterial femoral cannula. A Dacron-graft tube (Vascutek Terumo, Renfrewshire, Scotland, UK) was sutured to the distal part of the arch, which resulted in not damaging the removal of the stent-bare springs. In all cases there was no need to reattach the left subclavian artery separately. The supradiaphragmatic distal anastomosis was then performed. Subsequently, the supraaortic trunks cannulas were removed, and the proximal aortic suture was completed. Recovery of systemic arterial perfusion was established within 22 minutes, 25 minutes, and 36 minutes, respectively.
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Fig 2. (A) Type I endoleak after left hemi-arch stent-graft repair. (B, C, D) Incision of the uncovered proximal stent, removal of endograft neck, and selective cannulation for antegrade cerebral perfusion.
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Results
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No 30-day mortality was observed. Surgical procedure time ranged from 182 to 275 minutes, with a mean of 220 minutes. Total pump time was 130, 175, and 150 minutes, respectively, with a mean pump time of 151 minutes. Mean antegrade cerebral perfusion time was 25 minutes (range, 22 to 36 minutes). Postoperative intensive care unit stay was 2 days in all cases. Weaving from mechanical ventilation was achieved in all patients on the first postoperative day. No patients suffered acute renal failure, myocardial infarction, or respiratory failure. No permanent or transient stroke or paraplegia was observed. No reoperation for postoperative bleeding was needed. Patients presented in good health at 3-months follow-ups and procedure surveillance was obtained with contrast angiographic and computed tomographic scans, which were negative for any aortic complications.
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Comment
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Several previous studies have shown encouraging results of thoracic aortic stent-graft repair for both degenerative disease and acute or chronic dissection with mortality rates ranging from 2.1% to 16%, stroke rate of 7%, and paraplegia incidence rate of 3% [2–5]. However, 7% to 12% of urgent surgical conversion due to leakage at the proximal end of the thoracic endograft or stent migration [6], along with the presence of endoleaks at the patient's discharge (16%), highlights the necessity to interpret aortic stent-graft results with caution. Accordingly, some studies reported long-term results with a high incidence of thoracic stent-graft failure in aneurysmal and dissecting pathologies [5]. Most endoleaks were due to severe distortion and structural changes, probably related to modifications in the aneurysm sac after stent-graft insertion. Suboptimal results have been reported, even in patients in whom the distance between the left subclavian artery and the dissection tear, or the beginning of the aortic lesion to be covered by the stent was less than 2 cm [7]. Because of the frequent involvement of the left hemi-arch, stent implantation may lead to different complications, such as occlusion of the left subclavian artery, inadequate device placement, and insufficient seal of the proximal endograft neck related to low adaptability of the graft in the aortic curve, with consequent type I endoleak. These complications are difficult to be treated only through a percutaneous approach. Surgical strategies have been proposed for transposition or extra-anatomical bypassing of the left subclavian artery and left carotid artery to obtain a "lengthening of the branchless descending thoracic aorta" [4]. In our opinion such techniques should be reserved for patients with high surgical risk, also considering the effectiveness of selective cerebral perfusion with mild hypothermic circulatory arrest in reducing surgical mortality and neurologic morbidity during aortic arch surgery [8]. A surgical series on descending thoracic aortic repair showed a low mortality rate and optimal results for neurologic deficit [9] as well as medical treatment of acute type B aortic dissection, which produced optimal long-term results [10]. The presence of an uncovered proximal stent in the para-subclavian aorta does not allow a simple aortic cross clamping, even between the left carotid artery and left subclavian artery, because of the need to explant the endograft before the aortic reconstruction. In our experience, the distal endograft tract was easily removed with gentle traction without aortic lesions. In conclusion, our experience highlights caution in stent implant indication for isthmic aortic disease, considering the rapid increase of aortic diameter in case of stent failure for type I endoleak. Moreover, poststent surgical treatment is more complex and at higher risk than a primary surgical approach. We believe that device structural improvements with a stronger columnar sustain and a more adequate fixation are needed to make the endograft fully adaptable to the left hemi-arch. Therefore, thoracic aortic stent-graft failure for treatment of left hemi-arch diseases may become a new emergent aortic pathology. Open aortic procedure, rapid stent-graft explant and selective cerebral antegrade perfusion, through a left posterolateral thoracotomy allows a complete and safe left hemi-arch and descending thoracic aortic reconstruction.
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References
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- Mitchell RS, Dake MD, Sembra CP, et al. Endovascular stent-graft repair of thoracic aortic aneurysms. J Thoracic Cardiovasc Surg. 1996;111:1045–1062
- Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Eng J Med. 1999;340:1546–1552[Medline]
- Tailor PR, Gaines PA, McGuinness CL, et al. Thoracic aortic stent graft: early experience from two centers using commercially available devices. Eur J Vasc Endovasc Surg. 2001;22:70–76[Medline]
- Criado FJ, Clark NS, Barnatan MF. Stent graft repair in the aortic arch and descending thoracic aorta: a 4-year experience. J Vasc Surg. 2002;36:1121–1128[Medline]
- Dake MD, Milller DC, Nichell RS, et al. The "first generation" of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta. J Thoracic Cardiovasc Surg. 1998;116:689–703[Abstract/Free Full Text]
- Palma JH, Marcondes JA, Alves CM, Buffolo E, et al. Self-expandable aortic stent-graft of treatment of descending aortic dissections. Ann Thorac Surg. 2002;73:1138–1142[Abstract/Free Full Text]
- Alves CM, Palma JH, Marcondes JA, Buffolo E, et al. Endovascular treatment of thoracic disease: patient selection and proposal of a risk score. Ann Thorac Surg. 2002;73:1143–1148[Abstract/Free Full Text]
- Di Eusanio M, Schepens MA, Morshuis WJ, et al. Antegrade selective cerebral perfusion during operation on the thoracic aorta: factors influencing survival and neurologic outcome in 413 patients. J Thorac Cardiovasc Surg. 2002;124(6):1068–1070[Free Full Text]
- Biglioli P, Spirito R, Porqueddu M, et al. Quick, simple camping technique in descending thoracic aortic aneurysm repair. Ann Thorac Surg. 1999;67(4):1038–1043[Abstract/Free Full Text]
- Hata M, Shiono M, Inoue T, et al. Optimal treatment of type B acute aortic dissection: long-term medical follow-up results. Ann Thorac Surg. 2003;75:1781–1784[Abstract/Free Full Text]
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Abstract
Introduction
