Ann Thorac Surg 2006;82:308-310
© 2006 The Society of Thoracic Surgeons
Case report
Endovascular Treatment of a Thoracic Aortic Pseudoaneurysm After Previous Open Repair
Derek R. Brinster, MD
a
,
b
,
*
,
Desirae M. McKee, MD
c
,
Dawn M. Olsen, PA
c
,
Scott S. Berman, MD
d
,
Julio A. Rodriguez-Lopez, MD
c
a Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
b Department of Surgery, Harvard Medical School, Boston, Massachusetts
c Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute, Phoenix, Arizona
d Tucson Valley Vascular Surgery, Tucson, Arizona
Accepted for publication September 21, 2005.
* Address correspondence to Dr Brinster, Department of Surgery, Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 (Email: dbrinster{at}partners.org).
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Abstract
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The use of endovascular stents to treat descending thoracic aortic pathologies is emerging as a less invasive therapy to treat high-risk patients. This case report describes the presentation of a patient with a pulsatile mass on her back. The patient's computed tomographic scan revealed the mass to be an extension of a large psuedoaneurysm from the site of a previous repair of her thoracic aorta for a dissecting aneurysm several years earlier. The psuedoaneurysm was successfully treated with an endovascular stent and the patient was discharged home on postoperative day 5.
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Introduction
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Since the first reported successful repair of thoracic aortic aneurysm by Lam and Aram [1] in 1951, great progress has been made in the surgical management of this disease. Although open surgical repair is considered the traditional treatment for surgical diseases of the thoracic aorta, the technique of endoluminal stent-graft placement has recently been introduced for the repair of thoracic aneurysms, dissections, and traumatic ruptures [1–4].
We present an interesting case of a patient who underwent initial open, traditional repair of a descending thoracic aortic dissecting aneurysm in 2001, who subsequently had a psuedoaneurysm develop that arose from her tube graft, which was successfully treated with an endoluminal stent-graft.
A 74-year-old woman was referred in May 2005 to our hospital for evaluation of a large pulsatile mass on her left back (Fig 1), increasing intense back pain, and known history of a psuedoaneurysm of her descending thoracic aorta. The patient's past surgical history is significant for an open repair of a descending thoracic aortic dissection in April 2001, which was performed at an outside hospital. Her past medical history is significant for chronic hypertension and peptic ulcer disease.
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Fig 1. White arrow marks 5 cm x 4 cm x 4 cm pulsatile mass on patient's left back. Black arrows indicate patient's previous thoracotomy incision for repair of descending thoracic dissection.
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On arrival to our institution, the patient was hemodynamically stable with a blood pressure of 140/60 and a heart rate in the 80s. Laboratory values were within normal limits with a creatinine of 1.0. The patient's physical examination was notable for a left thoracotomy incision from her previous descending thoracic aorta repair and a large 5 cm x 4 cm x 4 cm pulsatile mass arising inferior to the most posterior aspect of the patient's thoracotomy incision (Fig 1).
Preoperative imaging revealed a saccular aneurysm 5 to 6 cm in size in the descending thoracic aorta that protruded through the chest wall at the level that corresponds to the pulsatile mass found on physical examination (Fig 2). The mass contained mural thrombus and protruded between the intercostal spaces. In addition, a distal descending thoracic aneurysm was noted to begin at the distal end of the previous thoracic graft and extend to the level of the aorta at the celiac artery takeoff. There was a chronic abdominal aortic dissection below the level of the celiac artery. There was retrograde flow from distal to proximal in the abdominal aortic dissection with the left renal artery arising from the false lumen.
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Fig 2. Preoperative computed tomography scanning. (A) Three-dimensional reconstruction with white arrow pointing to the area of graft kinking and nipple of extravasation and hatched chevron arrow indicating descending thoracic aortic aneurysm. (B) Saggital imaging with white arrow revealing pseudoaneurysm formation and protruding mass and hatched chevron arrow indicating descending thoracic aortic aneurysm. (C) Axial image revealing contrast enhanced imaging of site of pseudoaneurysm with thrombus formation and bony destruction of rib (white arrow). (D) Coronal image revealing kinked area of graft with "nipple" of extravasation surrounded by thrombus (white arrow).
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After careful review of the patient's surgical options, and after informed consent was obtained, the patient elected to undergo thoracic aortic endovascular stent grafting to treat her psuedoaneurysm and residual descending thoracic aortic aneurysm. The patient was taken to the operating room and bilateral percutaneous access of the common femoral arteries was obtained. An aortogram revealed the area of psuedoaneurysm formation arising from what seemed to be a kink in the patient's previous open tube graft (Fig 3a). An intravenous ultrasound examination was performed to obtain accurate measurements of the proximal and distal landing zones and to evaluate the patient's residual subdiaphragmatic dissection. Based on the patient's intravenous ultrasound measurements, a 40 mm x 100 mm thoracic aortic graft (W.L. Gore & Associates, Inc, Flagstaff, Arizona) was selected, which requires a 24-French introducer sheath. The patient's left external iliac artery was small and tortuous. Attempts at right common femoral artery access failed despite balloon angioplasty of the right external iliac. Therefore a right retroperitoneal approach was used to obtain adequate access for the 24-French sheath. A 10-mm Hemashield graft (Boston Scientific, Natick, MA) was sewn in an end-to-side fashion to the right common internal iliac artery, and the 24-French sheath passed through the graft and into the descending aorta.
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Fig 3. Operative aortogram. (A) White arrow indicates area of graft kinking and pseudoaneurysm formation. (B) Post-repair: white arrow indicates no pseudoaneurysm and mild correction of kinked graft from previous open repair.
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The first thoracic aortic graft (40 mm x 100 mm) was positioned and deployed directly over the psuedoaneurysm formation. An additional proximal thoracic aortic graft device (40 mm x 200 mm) was deployed proximal to the first graft to ensure adequate exclusion of the pseudoaneurysm and a third thoracic aortic graft device (40 mm x 150 mm) was deployed distally to treat the patient's distal thoracic aortic aneurysm, which was 8 cm in diameter. The endoluminal stent-grafts were profile ballooned with a Coda 40-mm balloon (Cook Group, Bloomington, IN) to ensure adequate radial apposition. The completion aortogram (Fig 3b) revealed complete treatment of both the aneurysm arising from the original kinked graft and the residual distal thoracic aneurysm. The 10-mm Hemashield graft was brought under the inguinal ligament and used as a right common iliac to the right common femoral artery repair conduit. Total contrast used was 429 cc of Omnipaque 300 (Nycomed, Princeton, NJ), and total operative time was approximately 150 minutes.
The patient was extubated in the operating room, had an uneventful recovery, and was discharged home on postoperative day 5. Pre-discharge contrast computed tomography revealed successful exclusion of the pseudoaneurysm and treatment of the descending thoracic aneurysm (Fig 4).
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Fig 4. Postoperative computed tomographic scan reveals (A) successful thoracic aortic stent-graft exclusion of pseudoaneurysm, and (B) successful exclusion of true aneurysm at the level just proximal to the celiac axis.
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Comment
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Open surgical repair of the descending thoracic aorta is the traditional treatment of patients with thoracic aortic aneurysms, psuedoaneurysm, and symptomatic dissections [5]. However, open surgical repair is associated with a 5% to 20% mortality rate for a primary operation, and an approximate paraplegia rate of 5% [6, 7]. Reoperations of the descending thoracic aorta are rare and carry an increased risk of morbidity and mortality. Undoubtedly, the high morbidity and mortality from open surgical repair include the substantial comorbidities of this elderly population as well as the morbidity associated with an open surgical procedure that generally requires a large thoracotomy, cross clamping of the aorta, cardiopulmonary bypass, and prolonged mechanical ventilation [8–11]. Because of this high morbidity and mortality rate associated with open surgical repair, the technique of endovascular stent grafting has several potential benefits due to its minimally invasive approach. Generally a femoral arterial cut-down or retroperitoneal approach is necessary to allow access to the aorta for stent graft placement, and the procedure requires no aortic cross-clamp time, no thoracotomy, and no cardiopulmonary bypass. Considering the extensive experience of this institution and others, the use of thoracic aortic stents has proven safe and effective in a variety of aortic pathologies [3, 4, 12, 13].
We believe that this is the first reported case of the treatment of a psuedoaneurysm arising from a previously replaced descending aorta with an endovascular graft. Because the natural history of psuedoaneurysms is to increase in size and potentially rupture, repair is indicated. Although the use of endovascular stents in the treatment of aortic abdominal psuedoaneurysms arising from sites of a previous open repair has been reported, the use of the thoracic endoluminal graft for this purpose has not [14]. This case demonstrates that the use of endoluminal grafts in reoperative thoracic aortic pathologies can be accomplished with low morbidity and mortality.
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References
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Abstract
Introduction
