Ann Thorac Surg 2007;84:1007-1008
© 2007 The Society of Thoracic Surgeons
Case Reports
Continued Aortic Aneurysmal Expansion After Thoracic Endovascular Stent-Grafting
Faisal G. Bakaeen, MDa,b,*,
Joseph S. Coselli, MDa,c,
Scott A. LeMaire, MDa,c,
Joseph Huh, MDa,b
a Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
b Michael E. DeBakey VA Medical Center, Houston, Texas
c Division of Cardiovascular Surgery, Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas
Accepted for publication March 23, 2007.
* Address correspondence to Dr Bakaeen, Department of Cardiothoracic Surgery, Michael E. DeBakey VAMC, OCL 112, 2002 Holcombe Blvd, Houston, TX 77030 (Email: fbakaeen{at}bcm.edu).
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Abstract
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We report the successful open repair of a thoracoabdominal aneurysm that had expanded after previous endovascular stenting. Aortic valve-sparing root replacement was performed as an initial step because the patient had significant aortic valve regurgitation caused by root enlargement. Continued aneurysmal dilatation after stenting of the thoracic aorta can lead to repair failure and therefore underscores the need for careful follow-up of patients after endografting.
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Introduction
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In March 2005, the Food and Drug Administration approved the first endovascular stent graft for descending thoracic aortic aneurysm repair. The midterm benefits of using this technology have been demonstrated [1, 2]. The procedure is usually well tolerated and perioperative mortality and paraplegia risks compare favorably with those of open surgical repair [3]. However, further dilatation of the aorta threatens the integrity of the proximal and distal anastomotic seals [4]. This time-related phenomenon can occur in the absence of detectable endoleak and leads to repair failure [5]. Ongoing pathologic processes in the arterial wall and persistent pressurization within the excluded aneurysm, or endotension, are potential mechanisms of continued aneurysmal growth.
The patient was a 72-year-old man who was a smoker with significant chronic obstructive pulmonary disease (forced expiratory volume in 1 second, 1.7 L) and other comorbidities including hypertension and hyperlipidemia. Two years earlier he had undergone endovascular repair of a descending thoracic aortic aneurysm. He now had aneurysmal enlargement of the aorta around and beyond the stent. In addition, at the age of 60 the patient had undergone an open repair of an infrarenal abdominal aortic aneurysm with a tube graft.
Follow-up imaging after the stent repair showed a descending thoracic aortic aneurysm that started at the left subclavian artery, encompassed the stent downstream, and extended below the diaphragm (Figs 1, 2).
Therefore the patient was referred to our institution for evaluation. Because of the extent and anatomic features of the aneurysm, as well as the patient’s desire to avoid further stenting, open repair was recommended.
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Fig 1. Aortic angiogram showing the relationship between the aneurysm and the stent proximally (left) and distally (right).
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Fig 2. Computed tomographic scan of the mid-stent level (left) and the distal extent of the stent (right).
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Preoperative echocardiography showed moderate to severe (grade 3+) aortic regurgitation with poor coaptation of the valve leaflets. The aortic annulus and root measured 28 and 50 mm, respectively. Coronary angiography showed normal coronary arteries. Given the extent of the thoracoabdominal aneurysm and the possibility that circulatory arrest would be necessary if proximal aortic clamping did not prove possible, we decided to address the aortic valve and root first.
The aortic valve was approached through a median sternotomy and was found to have normal leaflets. As anticipated, the cause of aortic regurgitation was annuloaortic ectasia associated with an aneurysm of the aortic root and proximal ascending aorta. Valve-sparing aortic root replacement was performed, as first described by David and Feindel [6], with a 34-mm Hemashield tube graft (Boston Scientific, Natick, MA). The patient had trace aortic regurgitation on postoperative echocardiography and was discharged home 8 days after surgery.
Three weeks after the initial operation, the patient had an excellent recovery and was deemed fit to undergo the second stage of the operation. Through a left thoracoabdominal incision and by using left heart bypass, cerebrospinal fluid drainage, and a clamp between the left carotid and left subclavian arteries, the aneurysm was repaired with a 30-mm Hemashield graft (Boston Scientific). The proximal anastomosis was immediately distal to the origin of the left subclavian artery and was beveled into the arch. The distal anastomosis was beveled to incorporate T11 and T12 intercostal arteries down to the level of the visceral vessels. The stent was not incorporated and was easily removed after the aorta was opened. The patient had postoperative atelectasis and pulmonary edema, but recovered well with appropriate treatment and was discharged home on postoperative day 16. Three months later the patient underwent an echocardiography that showed stable trace aortic regurgitation, and also a computed tomographic scan that showed a normal post-repair thoracoabdominal aorta.
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Comment
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Endovascular technology is gaining a foothold in the field of thoracic aortic aneurysm repair. It offers a much-desired minimally invasive approach and has produced acceptable midterm results [1, 2]. However, there are unique complications associated with endovascular repair of thoracic aneurysms. Therefore, although many of these complications can be treated through endovascular access, others require an open approach [4, 7].
This case demonstrates that the thoracoabdominal aorta can expand after endovascular therapy and stent seals can fail both proximally and distally. This potential problem underscores the importance of continued careful radiologic surveillance after endovascular stent placement. As published midterm studies of thoracic endovascular stenting mature into long-term studies, it will be interesting to see the rate of reintervention necessitated by time-related morphologic changes in the aorta. This information will become particularly important as the application of this technology widens to include younger and healthier patients with longer life expectancies and fewer risk factors that could compete with the risk of stent failure.
From among the many surgical options available, we chose a staged approach, starting with a David procedure to preserve the patient’s aortic valve and then performing open thoracoabdominal aneurysm repair. Another possible option in this type of patient, notwithstanding the technical challenges, is to take an endovascular approach to the thoracoabdominal aneurysm by using custom-made endografts or by stenting in conjunction with de-branching.
Continued aneurysmal dilatation after stenting of the thoracic aorta can lead to repair failure and therefore warrants continued surveillance. When this complication occurs, further intervention should be tailored to the anatomical morphology of the aorta and patient-related variables.
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Acknowledgments
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Dr Stephen N. Palmer, PhD, ELS, contributed to the editing of this article.
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References
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- Wheatley III GH, Gurbuz AT, Rodriguez-Lopez JA, et al. Midterm outcome in 158 consecutive Gore TAG thoracic endoprostheses: single center experience Ann Thorac Surg 2006;81:1570-1577.[Abstract/Free Full Text]
- Marcheix B, Dambrin C, Bolduc JP, et al. Midterm results of endovascular treatment of atherosclerotic aneurysms of the descending thoracic aorta J Thorac Cardiovasc Surg 2006;132:1030-1036.[Abstract/Free Full Text]
- Najibi S, Terramani TT, Weiss VJ, et al. Endoluminal versus open treatment of descending thoracic aortic aneurysms J Vasc Surg 2002;36:732-737.[Medline]
- Neragi-Miandoab S, Tuchak J, Bakhos M, Schwartz JP. Open repair of a new aneurysm of the thoracoabdominal aorta after endovascular stent placement J Thorac Cardiovasc Surg 2006;132:157-158.[Free Full Text]
- van Sambeek MR, Hendriks JM, Tseng L, van Dijk LC, van Urk H. Sac enlargement without endoleak when and how to convert and technical considerations Semin Vasc Surg 2004;17:284-287.[Medline]
- David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta J Thorac Cardiovasc Surg 1992;103:617-621.[Abstract]
- Parmer SS, Carpenter JP, Stavropoulos SW, et al. Endoleaks after endovascular repair of thoracic aortic aneurysms J Vasc Surg 2006;44:447-452.[Medline]
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Abstract
Introduction
