Ann Thorac Surg 2008;85:1115-1117. doi:10.1016/j.athoracsur.2007.04.120
© 2008 The Society of Thoracic Surgeons
How To Do It
A Novel Approach for the Endovascular Repair of the Small Thoracic Aorta: Customizing Off-the-Shelf Endoluminal Grafts to Treat a Post-Coarctation Pseudoaneurysm
Jacques Kpodonu, MD*,
Grayson H. Wheatley, III, MD,
James P. Williams, BS,
Julio A. Rodriguez-Lopez, MD,
Venkatesh G. Ramaiah, MD,
Edward B. Diethrich, MD
Department of Cardiovascular and Endovascular Surgery, Arizona Heart Hospital and Arizona Heart Institute, Phoenix, Arizona
Accepted for publication April 24, 2007.
* Address correspondence to Dr Kpodonu, Department of Cardiovascular and Endovascular Surgery, Arizona Heart Hospital and Institute, 2632 N 20th St, Phoenix, AZ 85006 (Email: jkpodonu{at}yahoo.com).
| Dr Wheatley discloses that he has a financial relationship with W. L. Gore & Associates.
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Abstract
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Surgical repair of post-coarctation pseudoaneurysm is associated with high morbidity and mortality. Endovascular stent grafting is a minimally invasive approach to manage this condition. The small thoracic aorta provides a dilemma for endovascular stent grafting using available commercially available thoracic endografts. We describe a hybrid approach including a novel technique to customize various components of the abdominal endoluminal grafts to repair a post-coarctation pseudoaneurysm. The patient is doing well at 1-year follow-up with no endoleaks.
Surgical repair has proven to be an effective treatment for primary aortic coarctation. Traditional surgical approaches include resection with an end-to-end anastomosis, subclavian flap aortoplasty, patch aortoplasty, and interposition graft. Potential complications at long-term follow-up include recurrent coarctation, hypertension, premature coronary artery disease, cerebrovascular disease, and anastomotic pseudoaneurysm [1, 2]. The reported rate of anastomotic pseudoaneurysm has been reported to be between 3% and 38% [3]. Open surgical repair for anastomotic pseudoaneurysm is associated with high morbidity and mortality. Endovascular management of post-coarctation pseudoaneurysm offers a less invasive treatment approach in high surgical risk patients.
A 49-year-old man with past medical history significant for hypertension had a primary surgical repair for coarctation of the aorta at the age of 20 years, which was an incidental finding of an enlarged thoracic aortic shadow on a routine preoperative chest x-ray film prior to knee surgery. A computed tomographic scan of the chest showed an enlarge pseudoaneurysm of the thoracic aorta involving the ostium of the left subclavian artery and extending beyond the site of previous repair (Figs 1A,
1B). The descending thoracic aorta was noted to be small in caliber. Due to the high risk associated with a redo operation, consent was obtained for a hybrid repair consisting of a left carotid artery to left subclavian artery bypass followed by endovascular exclusion of the pseudoaneurysm with a customized off-the-shelf abdominal endoluminal graft component through a research protocol.
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Fig 1. (A, B) Computed tomographic scan demonstrates a post-coarctation pseudoaneurysm involving the left subclavian artery.
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Technique
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A left carotid subclavian artery bypass was performed the day prior to the endovascular procedure, because the pseudoaneurysm involved the left subclavian artery as demonstrated in Figure 2. Percutaneous access of the left common femoral artery was performed with a 9-French sheath that was introduced. Thoracic arch aortogram was performed through the left sheath with a pigtail catheter to delineate the arch and descending thoracic aorta and aneurysm. An intravascular ultrasound was performed using a 8.2F Volcano Therapeutics probe (Rancho Cordova, CA) through the right common femoral artery sheath. The proximal neck measured 20 x 21 mm. The distal neck of the pseudoaneurysm measured 22 x 23 mm. The length of the aorta to be covered measured 14 cm. The smallest thoracic endoprosthesis is 26 mm in diameter and use of this device would represent a significant oversize compared with the thoracic aorta. A series of abdominal endoluminal graft components were chosen, but the delivery catheter for the device was too short to reach the thoracic arch. A Cook Zenith graft (Bloomington, IN) iliac limb extension (22 mm x 55 mm) was deployed on the back table and was reloaded into a 20F sheath, which was successfully delivered to the target area covering the stump of the left subclavian artery. This process was repeated a second time with a larger iliac leg extension (24 mm x 55 mm), and then finally with a Cook Zenith graft (Bloomington, IN) 28 mm x 103 mm bifurcated main body that had been customized for this procedure and was delivered through a 22F sheath. Included in this customization were the removal of the suprarenal fixation barbs and the removal of the gate area for the limbs (Fig 3). An angiogram was performed, which showed no endoleak with complete exclusion of the post-coarctation pseudoaneurysm. All wires and sheaths were removed and the right common femoral artery was closed in a transverse fashion with restoration of flow. An 8F Angio-seal closure device (St. Jude Medical, St. Paul, MN) was deployed to the left common femoral artery.
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Fig 3. Abdominal aortic aneurysm (AAA) Cook Zenith graft (Bloomington, IN) main body bifurcated endoluminal graft (ELG) (103 x 28 mm) customized by the removal of the suprarenal fixation barbs and the removal of the gate area for the limbs (see arrow), Cook Zenith graft iliac limb extensions (22 mm x 55 mm and 24 mm x 44 mm).
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The patient was discharged on postoperative day 2 in satisfactory condition. A computed tomographic scan of the chest was performed prior to discharge, which showed exclusion of the post-coarctation pseudoaneurysm with no detected endoleak (Figs 4A,
4B). The patient continues to do well at the 1-year follow-up.
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Fig 4. (A, B) Computed tomographic scan with endoluminal graft excluding post-coarctation pseudoaneurysm with no endoleak noted.
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Comment
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This case represents a novel approach of customizing off-the-shelf endovascular components for the small thoracic aorta. Until thoracic endoprostheses are developed that are smaller in diameter, this customized approach is the best solution when an endovascular approach is contemplated. Severe adult type coarctation accounts for 4% of congenital cardiovascular malformations, which are usually surgically corrected.
Stent graft repair of thoracic aneurysm has been shown to be feasible with acceptable mid-term results [4, 5]. Conservative treatment of aneurysms after surgical coarctation repair is associated with a rupture rate of 100% within 15 years in a single center experience [6]. Surgical repair of pseudoaneurysms after coarctation repair is associated with high morbidity and mortality, including paralysis of the recurrent laryngeal nerve (13.6% to 36%), phrenic nerve injury (5% to 6%), and bleeding, paraplegia, and death (13.8%) [7, 8]. Endovascular management of the small thoracic aorta poses a surgical challenge because the smallest commercially available thoracic endograft is 26 mm in diameter. Customizing off-the-shelf abdominal endoluminal graft components allows for the endovascular repair of the small thoracic aorta. Access can be achieved through the femoral approach or by iliac access through a retroperitoneal approach. The goal of therapy in post-coarctation pseudoaneurysm is to deploy a short stent graft to reduce the potential risk of paraplegia. Coverage of the left subclavian artery to gain a good proximal landing zone can be performed with minimal associated left upper extremity symptoms [9]; however, a left carotid artery to left subclavian artery bypass should be performed if symptoms of the upper extremity ischemia occur, presence of a left internal mammary graft, and a dominant left vertebral artery system.
In conclusion, off-the-shelf abdominal endoluminal grafts can be customized for use in the small descending thoracic aorta in the absence of commercially available thoracic endoluminal grafts.
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References
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- Webb G. Treatment of coarctation and late complications in the adult Semin Thorac Cardiovasc Surg 2005;17:139-142.[Medline]
- Bouchart F, Dubar A, Tabley A , et al. Coarctation of the aorta in adults: surgical results and long term follow-up. Ann Thorac Surg 200;70:1483–8.
- von Kodolitsch Y, Aydin MA, Koschyk DH, et al. Predictors of aneurismal formation after surgical correction of aortic coarctation J Am Coll Cardiol 2002;39:617-624.[Abstract/Free Full Text]
- Bavaria JE, Appoo JJ, Makaroun MS, Verter J, Zi-Fan Yu, Scott Mitchell RS. Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: a multicenter comparative trial J Thorac Cardiovasc Surg 2007;133:369-377.[Abstract/Free Full Text]
- Makaroun MS, Dillavou ED, Kes ST, et al. Endovascular treatment of thoracic aortic aneurysms: results of the phase II multicenter trial of the Gore TAG thoracic endoprosthesis J Vasc Surg 2005;41:1-9.[Medline]
- Cohen M, Fuster V, Steele PM, Driscoll D, McGoon DC. Coarctation of the aorta: long-term follow-up and prediction of outcome after surgical correction Circulation 1989;80:840-845.[Abstract/Free Full Text]
- Knyshov GV, Sitar LL, Glagola, MD, Atamanyuk MY. Aortic aneurysms at the site of the repair of coarctation of the aorta: a review of 48 patients Ann Thorac Surg 1996;61:935-939.[Abstract/Free Full Text]
- Ala-Kulju K, Heikkinen L. Aneurysm after patch graft aortoplasty for coarctation of the aorta: long term results of surgical management Ann Thorac Surg 1989;47:853-856.[Abstract/Free Full Text]
- Hausegger KA, Oberwalder P, Tiesenhausen K, et al. Intentional left subclavian artery occlusion by thoracic aortic–stent grafts without surgical transposition J Endovasc Ther 2001;8:472-476.[Medline]
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Abstract
Introduction
