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Ann Thorac Surg 2006;81:1875-1877
© 2006 The Society of Thoracic Surgeons

Case report

Unusual Case of Late Thoracic Stent Graft Failure After Cardioversion

Anthony D. Caffarelli, MD a , Filip Banovac, MD b , Stephen C. Cheung, MD b , Dominick Fleischmann, MD b , R. Scott Mitchell, MD a , *

a Department of Cardiovascular and Thoracic Surgery, Falk Cardiovascular Research Center, Stanford, California, USA
b Department of Radiology, Stanford University School of Medicine, Stanford, California, USA

Accepted for publication April 22, 2005.

* Address correspondence to Dr Mitchell, Stanford University, 300 Pasteur Dr, Stanford CA 94305-5407 (Email: rsmitch{at}stanford.edu).


Dr R. Scott Mitchell discloses a financial relationship with W. L. Gore & Associates, Inc.

 

   Abstract
Top
 Abstract
Introduction
 Comment
 Acknowledgments
 References
 
We report the unusual case of successful endovascular exclusion of a thoracic aortic aneurysm with subsequent thoracic aortic aneurysm reduction, and development of an interval, acute type III endoleak after cardioversion 5 years after stent graft deployment.

The endovascular approach for surgical pathologies of the descending thoracic aorta is being used with growing enthusiasm. This promising technology has very clear short-term advantages compared with conventional open surgery, but has encountered complications such as endoleaks, which have questioned the durability of stent grafts in the thoracic aorta.

A 77-year-old man with hypertension, atrial fibrillation, and chronic obstructive pulmonary disease was incidentally diagnosed with a thoracoabdominal aortic aneurysm in March 1997, during a workup for an episode of biliary colic. An abdominal ultrasound and a subsequent computed tomographic angiogram (CTA) of the patient revealed two segments of aneurysmal dilatation (ie, a supraceliac portion measuring 5 cm in maximum diameter and an infrarenal portion with a maximal diameter of 4.2 cm). Because of aneurysm size, lack of symptoms, and no evidence of a connective tissue disorder, the patient was treated conservatively with antihypertensive medication and surveillance with an annual CTA was recommended.

The follow-up CTA obtained in March 1998 demonstrated significant enlargement of the supraceliac aneurysm to 6.5 cm with minimal increase of the infrarenal component to 4.8 cm. Given the size and rapid growth, operative repair was recommended and the patient was considered a candidate for the Phase I Food and Drug Administration clinical trial of the Gore Thoracic EXCLUDER endoprosthesis (Gore Technologies, Flagstaff, AZ). In May 1998 the patient underwent successful exclusion of the thoracic component of his thoracic aortic aneurysm with a 40 mm x 20 cm endograft overlapped with a 40 mm x 10 cm endograft through a right iliac arterial approach. Postoperative and annual surveillance CTAs conducted to July 2003 revealed the thoracic endografts in stable position with 5 cm of overlap between the two endografts and no evidence of stent graft migration or endoleak.

The patient did well until September 2003 when he experienced an episode of unstable, rapid atrial fibrillation. At an outside emergency room, the patient received one synchronized, 100-Joule shock with successful conversion to sinus rhythm. After observation he was discharged, but returned to the emergency department 12 hours later after an acute episode of left mid-axillary chest pain. Excluding the cardioversion, there was no other history of antecedent trauma. Workup revealed a left pleural effusion and an elevated international normalized ratio to 3.7 international units. The CTA documented contrast medium outside the stent graft within the old aneurysm sac, suggesting a mid-graft leak (type III) occurring in the vicinity of the overlapping stent grafts (Fig 1). No wire fractures were identified.


Figure 1
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  		Fig 1. (A) Plain axial computed tomographic scan of the mid-thorax showing stent grafts in the descending thoracic aorta. There is hematoma around the aorta and presence of left pleural fluid, which shows an attenuation of 59 Hounsfield units and suggests hemothorax. (B) Contrast enhanced scan showing active contrast extravasation (arrow) that is contained by the periaortic hematoma. (C) Oblique sagittal maximal intensity projection of the descending thoracic aorta. Note the contrast leakage from the stented aorta (arrow). (D) Volume rendered image of the aorta showing relation of the leakage (arrow) to the aortic stent graft.

 
After hospital transfer, the patient was taken to the operating room for endograft exclusion of the endoleak. In the operating room, a type III endoleak was angiographically confirmed. Therefore, a retroperitoneal approach through the right common iliac artery, a 40 mm x 20-cm EXCLUDER stent graft (Gore Technologies) was deployed with elimination of the endoleak (Fig 2). The patient tolerated the procedure well and was extubated the following day. Unfortunately the patient's condition deteriorated over the next 21/2 months, which was attributable to his poor pulmonary status and physiologic reserve. The patient ultimately refused reintubation, and his wishes were honored by allowing him to peacefully expire with no further intervention. An autopsy was denied.


Figure 2
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  		Fig 2. (A) Intraoperative digital subtraction thoracic aortogram showing contrast leakage from the stented lumen (arrow). (B). Post-deployment aortogram revealing no contrast extravasation confirming exclusion of the type III endoleak.

 

   Comment
Top
 Abstract
 Introduction
 Comment
Acknowledgments
 References
 
We describe the case of a patient, with a descending thoracic aortic aneurysm that was successfully treated with endograft repair with 5 years of documented aneurysm exclusion, who developed a Type III endoleak immediately after a single cardioversion.

Endovascular stent graft placement has emerged over the last 10 years into a viable and less invasive alternative for repair of descending thoracic aortic aneurysms [1]. The technology has evolved from comparably simple first generation devices to soon to be commercially available second generation devices that have lower profiles and more innovative deployment mechanisms [2]. These advances have made endovascular stent grafting an attractive alternative treatment modality for patients with selected aortic pathologies whose conditions are either unfit for open surgery, mainly because of severe concomitant cardiopulmonary disease as was the case with our patient, or those that could be managed with conventional surgery, but only with a high operative risk [3]. However, long-term performance is uncertain with these devices, as endoleaks continue to emerge on surveillance imaging modalities.

Mid-graft or Type III endoleaks are defined as leaks originating from fabric holes due to disruption of the graft wall or an inadequate seal between endograft components. This can be due to inadequate graft overlap or it can occur as one component migrates away from its original position [4]. Continued pressurization of the aneurysm sac, as shown by the EUROSTAR experience [5], has a catastrophic relationship to aneurysmal rupture. As a result, any endoleak that pressurizes the aneurysm sac places the patient at risk and must be eliminated.

Our patient's case is quite unusual with the late development of a type III leak occurring in the vicinity of the overlapping graft components. It remains unclear whether this leak originated at the junction of the two grafts or through a disruption of the proximal component's material. No graft migration was apparent and our patient had a normal CTA just 2 months prior to his acute presentation showing no evidence of stent graft migration, wire fracture, endoleak, or aneurysmal dilation. Yet our patient, given the onset of his symptoms, had an acute endoleak develop. The temporal relationship of his acute presentation without any other antecedent trauma may implicate cardioversion as a possible causative factor.

The cause of this leak is still undetermined, but there have been reports of mechanical trauma as a cause of late complication in stent graft repair in abdominal aortic aneurysms. In one series, 4 patients had either a type I or III endoleak as a result of various intensities of mechanical trauma (2 from motor vehicle accidents, 1 from a traumatic fall, and 1 from an individual participating in vigorous rowing) [6]. In our patient, without evidence for stent graft migration or wire fracture, and without any other history of trauma, the exact cause of this type III endoleak remains conjectural. However the temporal relationship between the external cardioversion and the onset of symptoms suggests a causal relationship. Certainly myotonic spasm as seen with cardioversion would exert unusual external forces, and it is associated with a sudden transient increase in aortic pressure. Concomitant anticoagulation may have prevented an occult endoleak from sealing. This experience further emphasizes the necessity for lifelong follow-up of these patients.


   Acknowledgments
Top
 Abstract
 Introduction
 Comment
 Acknowledgments
References
 
Dr Anthony D. Caffarelli is a recipient of the Thoracic Surgery Foundation for Research and Education Fellowship Award.


   References
Top
 Abstract
 Introduction
 Comment
 Acknowledgments
 References
 

  1. Lambrechts D, Casselman F, Schroeyers P, et al. Endovascular treatment of the descending thoracic aorta Eur J Vasc Endovasc Surg 2003;26(4):437-444.[Medline]
  2. Thompson C, Gaxotte V, Rodriguez J, et al. Endoluminal stent grafting of the thoracic aortainitial experience with the Gore Excluder. J Vasc Surg 2002;35(6):1163-1170.[Medline]
  3. Orend K, Scharrer-Pamler R, Kapfer X, et al. Endovascular treatment in diseases of the descending thoracic aorta6-year results of a single center. J Vasc Surg 2003;37(1):91-99.[Medline]
  4. Buth J, Harris P, van Marrewijk C, et al. The significance and management of different types of endoleaks Semin Vasc Surg 2003;16(2):95-102.[Medline]
  5. Harris P, Vallabhaneni S, Desgranges P, et al. Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysmsThe EUROSTAR experience. J Vasc Surg 2000;32(4):739-749.[Medline]
  6. Krajcar Z, Gupta K, Dougherty KG. Mechanical trauma as a cause of late complicationsafter AneuRx Stent Graft repair of abdominal aortic aneurysms. Tex Heart Inst J 2003;30(3):186-193.[Medline]



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