Ann Thorac Surg 2006;81:2300-2302
© 2006 The Society of Thoracic Surgeons
Case report
Stent-Graft Repair of an Aortic Rupture Caused by Invasive Hemangiopericytoma
Pieter J.A. van der Starre, MD, PhD
a
,
*
,
Daniel Y. Sze, MD
b
,
Cosmin Guta, MD
a
,
R. Scott Mitchell, MD
c
,
Michael D. Dake, MD
b
a Department of Anesthesia, Stanford University School of Medicine, Stanford, California
b Department of Interventional Radiology, Stanford University School of Medicine, Stanford, California
c Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
Accepted for publication July 6, 2005.
* Address correspondence to Dr van der Starre, Department of Anesthesia, Stanford University School of Medicine, 300 Pasteur Dr, Stanford, CA 94305 (Email: pieterva{at}stanford.edu).
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Abstract
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We describe a patient with a history of hemangiopericytoma, who had hemoptysis develop due to a pseudoaneurysm of the thoracic aorta from an intrathoracic metastasis. Stent-graft repair successfully excluded the aneurysm from the aorta. Transesophageal echocardiography showed to be an important guide for correct placement of the device.
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Introduction
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Stent-graft repair has become an attractive treatment for thoracic aneurysms [1] and traumatic injuries and dissections [2], particularly in patients with significant co-morbidities and high surgical risk [3]. We present a report on the stent-graft treatment of a descending thoracic aortic rupture, caused by an invasive metastatic hemangiopericytoma in which a transesophageal echocardiography (TEE) contributed to the successful outcome.
A 56-year-old man underwent surgical removal of a hemangiopericytoma of the intracranial meninges 12 years ago, followed by postoperative external-beam, as well as gamma-knife irradiation. Because of multiple metastases in the next 10 years, he underwent surgical resection of the affected portions of vertebrae T8, T9, and T10, followed by radiation. Recently, metastases in L3 and the sacrum were treated with radiation. The patient still complained of severe thoracic and lower back pain, partially relieved by epidural analgesics.
During hospitalization for fever, sepsis, and mild hemoptysis an unenhanced computed tomographic scan showed numerous pulmonary metastases. During recovery he had several episodes of massive hemoptysis, and had a large retrocardiac mass develop as evidenced by chest roentgenogram. Suspecting pulmonary hemorrhage from a metastasis, a contrast-enhanced computed tomographic scan was performed, showing a ruptured pseudoaneurysm of the descending thoracic aorta at a region previously shown to be a pulmonary metastasis abutting the aorta (Fig 1). Surgical repair was deemed a poor option, given the condition of the patient who required intubation because of respiratory insufficiency.
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Fig 1. A contrast-enhanced computed tomographic image of the distal descending aorta revealed a large pseudoaneurysm in a location which previous scans showed a large pulmonary metastasis adjacent to the aorta. Contrast enhancement of the pseudoaneurysm was equivalent to that of the aorta. Note the orthopedic hardware from previous vertebral metastasis resections.
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After transfer to our hospital, written informed consent was obtained from the patient's representative to undergo a stent-graft repair under general anesthesia according to the approved protocol of the Stanford International Review Board (approval date, November 11, 2002). A TEE probe was inserted, and the precise location of the communication between the large intrathoracic tumor and the aorta was identified (Fig 2A) and confirmed by an aortogram (Fig 2B). A 26 mm x 10 cm stent-graft (Gore TAG; W. L. Gore, Inc, Flagstaff, AZ) was introduced through a right femoral artery cut down and was deployed over the site of rupture under guidance of fluoroscopy and TEE. A TEE with Doppler showed complete exclusion of the pseudoaneurysm, which was confirmed by contrast angiography. The patient was extubated on postoperative day 1 and was discharged from the hospital on day 6. Follow-up computed tomographic scan on day 3 showed no contrast enhancement of the large pseudoaneurysm (Fig 3). In 8 months of follow-up, the patient has had no recurrence of hemoptysis.
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Fig 2. (A) Transaxial color Doppler image from intraoperative transesophageal echocardiogram, showing a jet of arterial flow from the aorta into the pseudoaneurysm during systole. (B) Left anterior oblique aortogram corroborated the location of the communication (see arrow).
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Fig 3. Curved planar reformat of the postoperative computed tomographic angiogram confirmed complete exclusion and thrombosis of the pseudoaneurysm by the thoracic endograft. Note the ipsilateral pleural effusion and atelectasis, and the contralateral pulmonary metastases.
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Comment
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Hemangiopericytoma is a malignant mesenchymal tumor from the pericytes of Zimmerman, which are contractile spindle cells surrounding the capillaries and postcapillary venules [4]; it is included in the classification of soft tissue tumors [5], it accounts for <1% of all vascular tumors in adults, and it affects anatomic sites such as the extremities, pelvis, head, and neck. Two-year and 5-year survival rates are reported to be 93% and 86%, respectively [5]. The lungs and bones are the most common sites for metastasis. Primary intrathoracic hemangiopericytoma is a rare finding [6], and the ones reported were all surgically resected.
The patient in this case report had extensive thoracic metastases involving the posterior mediastinum and the lungs. Massive hemoptysis was probably caused by erosion through the wall of the aorta by a pulmonary metastasis. The choice to repair the erosion with a stent-graft was based on the unstable physical condition of the patient and the expected high risk of thoracotomy.
The conventional image-guidance for placement of a stent-graft is fluoroscopy, including intermittent contrast angiography. With TEE, the correct placement of the wire within the true lumen followed by positioning of the stent-graft can be continuously evaluated [7]. Complications such as endoleak or new dissections can be immediately identified [8]. In our patient, the covering of the orifice of the pseudoaneurysm was critical and easily guided by and confirmed with TEE. Only a total of 60 mL of contrast medium (given in two runs of contrast angiography) were required to confirm the correct deployment of the graft, and the patient's renal function was preserved.
In conclusion, thoracic aortic malignant pseudoaneurysm is a potential new indication for stent-graft repair. In patients at high surgical risk and with limited life expectancy, the minimization of invasiveness can result in favorable short-term and mid-term results. A TEE can be instrumental in guiding accurate placement of the devices and can limit the need for the use of nephrotoxic contrast media.
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References
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- Isselbacher EM. Thoracic and abdominal aortic aneurysms Circulation 2005;111:816-828.[Free Full Text]
- Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection N Engl J Med 1999;340:1546-1552.[Abstract/Free Full Text]
- Demers Ph, Miller DG, Mitchell RS, et al. Midterm results of endovascular repair of descending thoracic aortic aneurysms with first-generation stent grafts J Thorac Cardiovasc Surg 2004;127:664-672.[Abstract/Free Full Text]
- Stout AP, Murray MR. Hemangiopericytomaa vascular tumor featuring Zimmerman's pericytes. Ann Surg 1942;116:26-33.[Medline]
- Espat NJ, Lewis JJ, Leung D, et al. Conventional hemangiopericytoma Cancer 2002;95:1746-1751.[Medline]
- Biagi G, Gotti G, Bisceglie M, Lorenzini L, Toscano M, Sforza V. Uncommon intrathoracic extrpulmonary tumorprimary hemangiopericytoma. Ann Thorac Surg 1990;49:998-999.[Abstract]
- Schütz W, Gauss A, Meierhenrich R, Pamler R, Görich J. Transesophageal echocardiographic guidance of thoracic aortic stent-graft implantation J Endovasc Ther 2002;9:14-19.[Medline]
- Swaminathan M, Lineberger C, McCann RL, Mathew JP. The importance of intraoperative transesophageal echocardiography in endovascular repair of thoracic aortic aneurysms Anesth Analg 2003;97:1566-1572.[Abstract/Free Full Text]
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Abstract
Introduction
