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Ann Thorac Surg 2006;82:560-565
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

Thoracic Stent Grafting for Acute Aortic Pathology

Abdullah Kaya, MDa,*, Robin H. Heijmen, MD, PhDa, Tim Th. Overtoom, MDb, Jan-Albert Vos, MDb, Wim J. Morshuis, MD, PhDa, Marc A. Schepens, MD, PhDa

a Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
b Department of Interventional Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands

Accepted for publication March 20, 2006.

* Address correspondence to Dr Kaya, Department of Cardiothoracic Surgery, St. Antonius Hospital, Koekoekslaan 1, Nieuwegein 3435 CM, the Netherlands (Email: a_kaya33{at}hotmail.com).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Elective endovascular repair of the thoracic aorta has shown reduced morbidity and mortality when compared with open surgery. The number of studies describing the use of thoracic endovascular stent grafts for acute pathology is limited, however. The purpose of this study was to describe our increasing experience with stent grafting for acute thoracic aortic pathology.

METHODS: Since January 2002, 28 patients underwent endovascular stent graft treatment for various types of acute thoracic aorta diseases, including complicated Stanford type B dissection (n = 12), ruptured descending aorta aneurysms (n = 7), intramural hematoma (n = 4), traumatic rupture of the thoracic aorta (n = 2), aortopulmonary fistula (n = 2), and penetrating aortic ulcer (n = 1). These acute thoracic aortic syndromes were predominantly localized in the proximal descending thoracic aorta (75%). Talent stent grafts were used in 26 patients and Excluder stent grafts in 2 patients.

RESULTS: Stent graft deployment at the intended position was successful in all patients. There was 1 intraoperative death (3.6%), due to acute myocardial infarction, after successful exclusion of the lesion with a stent graft. Hospital mortality was 21.4% (n = 6). Four of 6 hospital deaths, however, were directly related to the severely compromised clinical status preoperatively, including extensive bowel ischemia and irreversible cerebral damage after resuscitation. New neurologic symptoms were seen in 4 patients. The majority of the neurologic symptoms improved and faded away during hospital stay. Mean follow-up was 11 months (range, 1 to 31), and all the hospital survivors (n = 22) were alive. There was 1 nonrelated stroke 4 months postoperatively. During follow-up, 2 patients required transposition of the left subclavian artery for malperfusion, and 2 patients required a second stent graft procedure for endoleak. Additionally, 2 patients with early type II endoleaks were treated conservatively, and 1 of them sealed spontaneously at 6 months.

CONCLUSIONS: Thoracic stent grafting for acute aortic pathology is feasible in critically ill patients. Postoperative morbidity and mortality is predominantly related to the compromised preoperative clinical status, illustrating its use as salvage strategy.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Endovascular stent grafting is a less-invasive treatment for descending thoracic aorta pathology and may be considered an alternative treatment option for open surgical repair in selected patients with suitable aortic anatomy. In elective cases, various studies have shown the technical feasibility, effectiveness, and safety of this technology, with low mortality and morbidity rates [1, 2]. Long-term results are still awaited.

Open surgical treatment of acute pathology of the descending thoracic aorta, however, is associated with significant mortality and morbidity. Whereas in elective treatment the mortality rate for surgical repair of descending thoracic and thoracoabdominal aortic aneurysms varies between 6% and 10%, this percentage increases as much as sixfold in patients requiring emergent surgical treatment [3–8]. Risk of postoperative pulmonary complication, paraplegia, or renal failure is considerably increased in emergent surgical interventions [5].

It is conceivable that the reported benefit of endovascular aortic repair in elective treatment may reduce morbidity and mortality rates in acute aortic repair. In this study, we report our experience with endovascular stent grafting for various diseases of the descending thoracic aorta in the acute setting.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
Since July 1997, 90 patients had an endovascular stent graft repair of the thoracic aorta at our institution. Initially, only elective cases were treated with this less invasive technique. From January 2002 through January 2005, 28 patients (31.1%; 17 men) with a mean age of 64 years (range, 26 to 83) with acute thoracic aorta disease were treated by endovascular stent grafting. In the same period, a few patients with unsuitable aortic anatomy were treated by conventional open repair. The Ethics Committee approved the retrospective study and waived the need for patient consent.

Aortic pathology treated by endovascular stent grafting (Table 1) consisted of Stanford type B dissection (n = 12; 42.9%), intramural hematoma with complicated course (n = 4; 14.3%), ruptured thoracic aorta aneurysm (n = 7; 25.0%), traumatic aortic rupture (n = 2; 7.1%), aortopulmonary fistula (n = 2; 7.1%), and symptomatic penetrating atherosclerotic ulcer (n = 1; 3.6%).


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  		Table 1. Thoracic Aorta Pathology (n = 28)
 
In all cases of acute aortic dissection, there was a complicated course, including hematothorax due to rupture (n = 6), distal malperfusion of the lower limbs or viscera (n = 2), and complete proximal obstruction resulting in acute lower body ischemia in 1 case (Fig 1). Three patients were treated because of persistent thoracic pain in spite of adequate antihypertensive therapy.


Figure 1
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  		Fig 1. (A, B) Aortic angiogram demonstrates complete proximal obstruction due to type B aortic dissection. (C) Angiographic result after placement of an endovascular stent graft.

 
Two cases with an intramural hematoma presented with hematothorax as a complicating factor (Fig 2), and 2 other patients had persistent pain in spite of adequate medical therapy.


Figure 2
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  		Fig 2. (A, B) Computed tomography scan and aortic angiogram shows a perforated intramural hematoma. (C, D) Result after complete sealing of the perforation site with an endovascular stent graft after 12 months' follow-up.

 
The ruptured thoracic aorta aneurysms were saccular in 1 patient and fusiform in 6 patients (Fig 3), and hematothorax was present in all. Maximal aneurysmal diameter averaged 56 ± 18 mm. The cause of the aneurysms was atherosclerosis, and the location was the proximal (n = 4) and mid (n = 3) descending aorta. The 2 patients with a contained traumatic rupture of the thoracic aorta were hemodynamically stable and treated within 2 days after trauma (Fig 4).


Figure 3
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  		Fig 3. (A) Computed tomography scan demonstrates a ruptured thoracic aorta aneurysm. (B) The patient survived the acute period after endovascular stent grafting.

 

Figure 4
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  		Fig 4. (A) Aortic angiogram shows extraluminal contrast after high energetic trauma. (B) Complete sealing of the traumatic rupture site with intentional subclavian artery ostium coverage.

 
An aortopulmonary fistula was seen in patients with a history of thoracic aorta surgery. One patient, who had a resection of a coarctation of the descending aorta 27 years ago, had a post-stenosis aneurysm and presented with acute rupture and hemoptysis (Fig 5). Another patient with hemoptysis was recently operated on for a postdissection descending aorta aneurysm and had a false aneurysm 2 months thereafter, which had ruptured. The single case treated by endovascular stent grafting for penetrating atherosclerotic ulcer of the descending aorta had hematothorax and persistent pain.


Figure 5
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  		Fig 5. (A, B) Computed tomography scan (reconstruction) and aortic angiogram illustrating a post-stenosis aneurysm. This patient had symptoms of hemoptysis, which disappeared after stent grafting with intentional subclavian artery ostium coverage (C).

 
Sixteen (57.1%) patients were treated the same day on admission (emergently) and 12 patients within days (urgently). The time interval between diagnosis and treatment by endovascular stent grafting ranged from 3 hours to 6 days. There were 22 patients (78.6%) referred from another hospital. Six patients (21.4%) were preoperatively intubated and mechanically ventilated. Hemodynamically unstable condition at the time of operation was present in 2 patients. All patients had undergone computed tomography scanning for diagnostic purposes. Six patients (21.4%) had follow-up with intra-arterial angiography for coronary angiography purpose or to localize the exact position of the lesion. Comorbid medical conditions included hypertension (n = 19, 67.9%), renal dysfunction (n = 8, 28.6%; serum creatinine of 133 to 394 µmol/L), coronary artery disease with previous myocardial infarction (n = 4, 14.3%), and chronic obstructive pulmonary disease (n = 4, 14.3%). Eight patients (28.6%) had a history of previous thoracic aortic surgery (n = 6, 21.4%; ascending aorta in 2, ascending aorta, arch replacement plus elephant trunk in 1 patient, proximal descending aorta in 2, and ascending plus descending aorta replacement in 1 patient) or abdominal aortic surgery (n = 2, 7.1%).

Aortic pathology was predominantly localized in the proximal descending thoracic aorta (n = 21, 75.0%). In 6 patients (21.4%), the location was midthoracic; and in 1 patient (3.6%), the distal thoracic aorta was involved.

Two types of stent graft prostheses were used: the Talent LPS (Medtronic AVE, Cupertino, California [n = 26, 92.9%]) and the Excluder (W.L. Gore & Associates, Flagstaff, Arizona [n = 2, 7.1%]). The type of stent graft was selected only upon availability and surgeon's preference. Since November 2003, a small stock of standard-sized Talent stent graft has been available at our institution, providing 81% of stent grafts necessary to treat all acute thoracic aortic pathology. No custom-made stent grafts were used. A total of 49 stent grafts were implanted (mean, 1.75 stent grafts per patient). Seven patients (25.0%) needed 2 stent grafts, and 5 patients (17.9%) required more than 2 stent grafts; 1 patient needed 5 stent grafts for total exclusion of the lesion. Stent graft diameter ranged from 28 to 46 mm, and the mean was 34 mm. Only in the treatment of thoracic aorta aneurysms was the stent graft oversized by 10% to 20% compared with the diameter of the aortic neck on computed tomography scanning for adequate fixation. In cases of acute dissection or traumatic rupture, there was no oversizing or balloon dilatation done.

Figure 6 shows the anatomical landing zone according to the Tokyo consensus 2001 [9]. The proximal end of the stent graft was zone 2 in 12 patients, zone 3 in 9 patients, zone 4 in 6 patients, and in an elephant trunk in 1 patient. That resulted in intentional stent graft coverage of the ostium of the left subclavian artery in 12 cases (42.9%).


Figure 6
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  		Fig 6. Anatomical landing zone (Z) for the proximal end of the stent graft. (Z 0: n = 0; Z 1: n = 0; Z 2: n = 12; Z 3: n = 9; Z 4: n = 7.)

 
The procedure of stent graft insertion and deployment was performed under general anesthesia and has been described before [10]. The common femoral artery (right, n = 23; left, n = 4) could be used for introduction of the stent graft system in all but 1 case (n = 27, 96.4%). In 1 patient, we converted to a retroperitoneal approach successfully. In the case of stent graft deployment in the aortic arch or proximal descending thoracic aorta, systemic arterial pressure was reduced to 70 mm Hg systolic using sodium nitroprusside to reduce the risk of downstream migration upon deployment. Routine surveillance included contrast-enhanced spiral computed tomography scans before discharge, and at 3 and 12 months after the procedure and yearly thereafter.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
In all 28 patients, the stent graft was deployed successfully at the intended position. Intraoperative control angiography demonstrated adequate exclusion of the lesion in all cases. There was 1 intraoperative death (3.6%). This patient with a ruptured aneurysm had a successful endovascular stent graft procedure in emergency. During wound closure, the patient had a massive myocardial infarction with fatal course. Immediate transesophageal echocardiography excluded retrograde dissection or recurrent rupture; autopsy confirmed the suspected cause of death.

Additional procedures performed immediately after endovascular stent grafting in the operating room were drainage of hematothorax in 8 patients and balloon dilation of the iliacofemoral route in 1 patient to allow passage of the stent graft, followed by embolectomy. Median intensive care unit stay was 1.5 days (range, 0 to 27). Six patients needed ventilatory support for more than 48 hours, and 8 patients for less than 1 hour. Six patients went to the ward on the same day after the endovascular stent graft procedure. Postoperatively, video-assisted thoracoscopy was performed to remove clots from the pleural space (n = 3), coiling the ostium of the subclavian artery successfully to prevent a type II endoleak from a covered subclavian artery (n = 1), and repeated balloon inflation of the proximal end of the stent graft successfully for proximal type I endoleak (n = 1) [11]. There was no myocardial infarction or need for dialysis. A groin hematoma or superficial infection was seen in 3 patients. Median hospital stay was 12 days (range, 4 to 64).

Overall hospital mortality was 21.4% (n = 6). In addition to 1 intraoperative death, 5 patients died postoperatively. The patient with acute occlusion of the proximal descending aorta due to dissection died of persistent massive visceral ischemia on the second postoperative day. In retrospect, the period from symptom development to final treatment with good angiographic result had exceeded 6 hours, owing to delayed transfer. Another patient with a ruptured type B dissection had been extensively resuscitated preoperatively and was treated in an emergency setting. Postoperatively, computed tomography scan of the cerebrum showed major postanoxic encephalopathy, and she died subsequently. The third patient who died in hospital had a successful endovascular exclusion of a ruptured saccular aneurysm of the proximal descending aorta. Because of lack of intensive care unit capacity, he was transferred to the referring hospital where, on the third postoperative day, he died because of recurrent bleeding. Autopsy revealed adequate sealing proximally and distally of the stent graft; there was, however, a connection between the left subclavian artery and the aneurysm sac. Conceivably, a significant type II endoleak from the subclavian artery was the cause of recurrent bleeding.

Another patient with a ruptured descending thoracic aorta aneurysm died acutely on the sixth postoperative day after successful endovascular therapy. Because of the intraoperative finding of a left vertebral artery originating from the aortic arch, the stent graft was positioned distal to the ostium of the left subclavian artery. consequently, the stent started in the proximal descending aorta, which contained a retrograde intramural hematoma. Postoperatively, severe systolic hypertension occurred despite adequate medication. At autopsy, a new rupture site proximal to the first stent graft was demonstrated that was potentially due to migration of the bare spring through the fragile intimal membrane. The last patient who died in the hospital was 83 years old and was treated by endovascular stent grafting for a ruptured descending aorta aneurysm. Postoperatively, he was in marginal respiratory condition, which severely deteriorated, and he died on the 12th postoperative day.

New neurologic symptoms were observed and diagnosed by computed tomography scan in 4 patients postoperatively: a subarachnoid hemorrhage (n = 1), monoparesis of the left leg (n = 1), and hemipareses (n = 2). Symptoms resolved completely in all patients during their postoperative stay.

Follow-up was 100% complete (mean, 11 months; range, 1 to 31). There were no late deaths. One nonrelated stroke occurred at 4 months postoperatively. During follow-up, in 2 patients a transposition of the left subclavian artery to the left common carotid artery was necessary, because of forearm malperfusion. There were 2 endovascular reinterventions performed. In 1 patient a false aneurysm developed proximal to the stent graft in the distal arch 6 months postoperatively; this patient received a second stent graft proximal to the first stent graft after transposition of the left subclavian artery. In the second patient, the stent graft had sealed a new intimal tear distal to the stent with persistent false lumen flow. At 7 months, she received a second stent graft distal to the first stent graft, excluding the false lumen at the thoracic aorta completely. In the abdominal aorta, however, the perfusion of the false lumen persisted, probably owing to preexistent reentries.

We have noted 4 patients with type II early endoleaks. Two patients died of other causes during their hospital stay. In 1 patient, the endoleak sealed spontaneously at 6 months. In another patient, the endoleak still persists at 10 months, without diameter increase of the aneurysm. Two late endoleaks (type II) have occurred, sealing spontaneously at 6 months, and still persisting at 11 months.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
The recent development of less-invasive aortic repair may have its impact on the high rate of morbidity and mortality that is associated with conventional open surgical repair for acute aortic pathology [3–8]. In our experience, there was 1 intraoperative death due to acute myocardial infarction. Overall hospital mortality was 21.4%. Four of 6 patients died, however, because of a severely compromised clinical condition preoperatively. An evaluation of the literature on hospital mortality with emergency endovascular intervention for acute thoracic aorta pathology shows large variation [12–15]. This variation is mostly due to the enormous difference between the clinical condition of the acutely ill patient at the time of intervention. Treatment of these critically ill patients, who are often considered not amenable to open surgical repair because of comorbid illnesses, will reflect on the observed mortality rates.

No paraplegia or paraparesis occurred. The majority of stent grafts, however, were deployed at the proximal thoracic aorta. In 2 patients, nonpermanent ischemic neurologic events were observed that were potentially due to air or debris emboli, as both patients had had their stent grafts positioned in the aortic arch. Reports about conventional surgical intervention of acute thoracic aorta pathology give higher incidence rate of neurologic complications [5–7].

Arterial access difficulty was observed in 1 patient only (3.6%). Even after balloon dilatation of the iliacofemoral arteries, it was not possible to insert the stent graft device, so we converted to a retroperitoneal approach successfully. Doss and associates [14] reported access failure of 6.2% and White and associates [16] reported 27% of access complications. Access problems may be predominantly encountered in small females with atherosclerotic pathology. The location of the acute thoracic aorta pathology is mostly in the proximal descending thoracic aorta (75%). Although we prefer to transpose the left subclavian artery to lengthen the proximal fixation in all elective cases as a separate procedure before stent grafting, in acute thoracic aortic pathology, the ostium of the left subclavian artery is overstented whenever necessary (43%). Two patients had progressive symptoms of a subclavian steal syndrome during follow-up, necessitating transposition, with complete relief of symptoms. One patient died after successful exclusion of a ruptured saccular aneurysm, conceivably of a large type II endoleak from the overstented left subclavian artery, owing to a reversal of flow in the ipsilateral vertebral artery. In emergent and urgent cases, anatomy of the vertebral, carotid, and vertebrobasilar system is not known beforehand. Overstenting of the ostium of the left subclavian artery in acute thoracic aorta syndromes to lengthen the proximal landing zone is generally well tolerated, as confirmed in earlier experience [17, 18]. Mild ischemic symptoms may develop, but that problem can be solved by subsequent transposition of the left subclavian artery to the left common carotid artery.

A stock of stent grafts in the hospital may be helpful in emergent endovascular stent graft treatment of acute thoracic aorta pathology. Since November 2003, we have had the availability of a stock of standard-sized Talent stent grafts in our institution. Diameters range from 28 to 46 mm. Since their availability, most (81%) of the prostheses used for emergency cases came from the stock in our institution.

In conclusion, thoracic stent grafting for acute aortic pathology is feasible in critically ill patients. Postoperative morbidity and mortality is predominantly related to the compromised preoperative clinical status. The availability of such a rapid, less-invasive treatment for acute aortic pathology, however, may result in emergency treatment of patients with malignant prognosis. That will reflect on observed mortality rates. More patients are now eligible for emergent treatment who would otherwise have been denied open surgery because of expected high mortality rates.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
We acknowledge Vincent Blinde for the preparation of the figures.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Dake MD, Miller DC, Semba CP, et al. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms N Engl J Med 1994;331:1729-1734.[Abstract/Free Full Text]
  2. Nienaber CA, Fattori R, Lund G, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement N Engl J Med 1999;340:1539-1545.[Abstract/Free Full Text]
  3. Coselli JS, Conklin LD, LeMaire SA. Thoracoabdominal aortic aneurysm repairreview and update of current strategies. Ann Thorac Surg 2002;74(Suppl):1881-1884.
  4. Schepens MA, Vermeulen FE, Morshuis MJ, et al. Impact of left heart bypass on the results of thoracoabdominal aortic aneurysm repair Ann Thorac Surg 1999;67:1963-1967.[Abstract/Free Full Text]
  5. LeMaire SA, Rice DC, Schmittling ZC, et al. Emergency surgery for thoracoabdominal aortic aneurysms with acute presentation J Vasc Surg 2002;35:1171-1178.[Medline]
  6. Crawford ES, Hess KR, Cohen ES, et al. Ruptured aneurysm of the descending thoracic and thoracoabdominal aorta Ann Surg 1991;213:417-425.[Medline]
  7. Mastroroberto P, Chello M. Emergency thoracoabdominal aortic aneurysm repairclinical outcome. J Thorac Cardiovasc Surg 1999;118:477-482.[Abstract/Free Full Text]
  8. Doss M, Balzer J, Martens S, et al. Surgical versus endovascular treatment of acute thoracic aortic rupturea single-center experience. Ann Thorac Surg 2003;76:1465-1470.[Abstract/Free Full Text]
  9. Mitchell RS, Ishimaru S, Ehrlich MP, et al. First international summit on thoracic aortic endograftingroundtable on thoracic aortic dissection as an indication for endografting. J Endovasc Ther 2002;9(Suppl 2):98-105.[Medline]
  10. Heijmen RH, Deblier IG, Moll FL, et al. Endovascular stent-grafting for descending thoracic aortic aneurysms Eur J Cardiothorac Surg 2002;21:5-9.[Abstract/Free Full Text]
  11. White G, Yu W, May J, et al. Endoleak as a complication of endoluminal grafting of abdominal aortic aneurysmsclassification, incidence, diagnosis, and management. J Endovasc Surg 1997;4:152-168.[Medline]
  12. Grabenwoger M, Fleck T, Czerny M, et al. Endovascular stent graft placement in patients with acute thoracic aortic syndromes Eur J Cardiothorac Surg 2003;23:788-793.[Abstract/Free Full Text]
  13. Iannelli G, Piscione F, Di Tommaso L, et al. Thoracic aortic emergenciesimpact of endovascular surgery. Ann Thorac Surg 2004;77:591-596.[Abstract/Free Full Text]
  14. Doss M, Wood JP, Balzer J, et al. Emergency endovascular interventions for acute thoracic aortic rupturefour-year follow-up. J Thorac Cardiovasc Surg 2005;129:645-651.[Abstract/Free Full Text]
  15. Hansen CJ, Bui H, Donayre CE, et al. Complications of endovascular repair of high-risk and emergent descending thoracic aortic aneurysms and dissections J Vasc Surg 2004;40:228-234.[Medline]
  16. White R, Donayre C, Walot I, et al. Endovascular exclusion of descending thoracic aortic aneurysms and chronic dissectionsinitial clinical results with the AneuRx device. J Vasc Surg 2001;33:927-934.[Medline]
  17. Rehders TC, Petzsch M, Ince H, et al. Intentional occlusion of the left subclavian artery during stent-graft implantation in the thoracic aortarisk and relevance. J Endovasc Ther 2004;11:659-666.[Medline]
  18. Görich J, Asquan Y, Seifarth H, et al. Initial experience with intentional stent-graft coverage of the subclavian artery during endovascular thoracic aortic repairs J Endovasc Ther 2002;9(Suppl):39-43.



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