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Closure of a Penetrating Ulcer of the Descending Aorta Using an Amplatzer Occluder
Closure of a Penetrating Ulcer of the Descending Aorta Using an Amplatzer Occluder Thomas Kleisli, MD, and Grayson H. Wheatley III, MD Department of Cardiovascular Surgery, Arizona Heart Institute, Phoenix, Arizona
Symptomatic patients with penetrating atherosclerotic ulcers of the descending thoracic aorta have traditionally been treated by using an open surgical repair. The emergence of thoracic aortic stent-graft technologies has introduced a less invasive treatment option, which often involves covering excess portions of a normal aorta with stent-graft material. We describe the mid-term follow-up of a patient with a symptomatic penetrating atherosclerotic ulcer of the descending thoracic aorta treated with an Amplatzer septal occluder device (AGA Medical Corp, Plymouth, MN), which is typically used for structural heart disease. (Ann Thorac Surg 2009;88:e18 –9) © 2009 by The Society of Thoracic Surgeons
P
enetrating atherosclerotic ulcers (PAUs), along with intramural hematomas, represent focal aortic disease processes within the spectrum of acute aortic syndrome [1–3]. Both symptomatic patients with PAU and those with acute rupture have traditionally been treated with an open surgical repair. Recently, endovascular stent-grafting has emerged as a less-invasive treatment option [4]. However, with the latter approach, an excess amount of normal aorta proximal and distal to the excluded PAU is covered by stent-graft material to achieve suitable landing zones for the stent-graft. We describe a novel localized treatment option for a symptomatic patient with an expanding PAU of the descending thoracic aorta (DTA) using a 35-mm Amplatzer Cribriform Occluder (AGA Medical Corp, Plymouth, MN). A 60-year-old woman with hypertension and an 8-month history of symptomatic mid-back pain was referred for evaluation. Four years prior, she underwent successful repair of an acute type A aortic dissection along with surgical replacement of her aortic arch and proximal
Accepted for publication June 23, 2009. Address correspondence to Dr Wheatley, Arizona Heart Institute, 2632 N 20th St, Phoenix, AZ 85006; e-mail: [email protected].
DTA. A multi-slice computed tomographic (MSCT) scan revealed a dilated and ectatic DTA with no focal aortic deficits and no definitive source for her back pain. A repeat MSCT scan 3 months later for increased back pain demonstrated a new PAU (measuring 1.5 ⫻ 1.8 cm) in the mid-DTA, which was located well away from the prior surgical anastomosis in the proximal DTA. Her back pain was adequately controlled with pain medications and she remained hemodynamically stable. A follow-up MSCT scan performed 1 month later demonstrated an increase in size of the PAU to 2.3 ⫻ 2.8 cm (Figs 1A and 1B), with concomitant increase in the patient’s back pain, which became refractory to oral pain medications. Various treatment options were considered for her expanding, symptomatic PAU of the DTA, including open surgical repair and endovascular stent-grafting. The patient refused open surgical repair. The diameters of the DTA proximal and distal to the PAU were 42 mm, and at the time of her presentation, no approved thoracic aortic stent-graft was large enough in diameter to accommodate her DTA. Therefore we offered her percutaneous repair of the PAU using an Amplatzer septal occluder device (AGA Medical Corp). After obtaining informed consent, the patient was taken to the hybrid operating suite where percutaneous vascular access was obtained through the right common femoral artery. A thoracic aortogram demonstrated the PAU in the mid-DTA with a focal neck. Intravascular ultrasound confirmed the diagnosis as well, in addition to verifying that the diameters of the DTA were too large to accommodate commercially available stent-grafts at that time. We selectively engaged the PAU through a 9F sheath in the right common femoral artery and deployed the 35-mm Amplatzer Cribriform Occluder (AGA Medical Corp) into the PAU. One disk of the device was located within the PAU, whereas the other was in the flow lumen of the DTA. A completion angiogram demonstrated successful exclusion of the PAU with the occluder device. The vascular access site in the right groin was closed using an 8F Angioseal closure device (St. Jude Medical, St. Paul, MN). A MSCT scan on postoperative day 1 demonstrated adequate exclusion of the PAU. Her back pain resolved immediately after treatment, and she experienced an uneventful recovery. She was maintained on a full strength daily aspirin and MSCT scans at 6 months and 12 months postoperatively, which showed successful exclusion of the PAU without evidence of disk fracture or thrombus formation (Fig 1C).
Fig 1. (A, B) Preoperative multi-slice computed tomographic scan of the thoracic aorta reveals a PAU in the descending thoracic aorta (arrows). (C) Postoperative multi-slice computed tomographic scan of the descending thoracic aorta demonstrates successful deployment of the 35-mm Amplatzer Cribriform Occluder (arrow) (AGA Medical Corp, Plymouth, MN).
© 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/09/$36.00 doi:10.1016/j.athoracsur.2009.06.092
Ann Thorac Surg 2009;88:e18 –9
Comment With increased use of MSCT, an increasing number of aortic abnormalities are being identified, and our understanding of the development and progression of localized aortic diseases is improving. The PAU, a variant of acute aortic syndrome, was initially described in 1934 by Shennan [1], but this has only recently been acknowledged as a distinct pathologic variant of classic false lumen aortic dissection [2, 3]. Penetrating atherosclerotic ulcers are atherosclerotic lesions that ulcerate and disrupt the internal elastic lamina, leading to the development of a localized intramural hematoma due to erosion of aortic vasa vasorum by the ulcer. Potential added complications of PAU include pseudoaneurysm formation after breaking through the adventitia, progression to overt aortic dissection, or rupture in as many as 40% of patients [4]. Penetrating atherosclerotic ulcers frequently involve the DTA and are very uncommon in the ascending arch or abdominal aorta [3]. Differentiation of PAU from other causes of acute aortic syndrome, such as intramural hematoma and aortic dissection is difficult, as the clinical presentations of these diseases (ie, sudden onset of severe chest or back pain) may be very similar. In addition, PAU may have more chronic symptoms with chronic back pain unrelated to musculoskeletal disorders [3]. Previous reports have observed PAU in 2.3% to 11% of symptomatic patients with suspected acute aortic syndrome, but the actual incidence of PAU remains unknown [4]. This report describes the successful 12-month follow-up of a novel percutaneous treatment option for PAU of the DTA with an Amplatzer cccluder device. This approach offers several advantages [5, 6]. First, the risk of paraplegia after treatment could be significantly decreased as a result of minimal coverage of intercostal arteries, preserving spinal cord perfusion. Second, vascular access for this device is safely approached using percutaneous techniques and would avoid an incision in the groin, making it a realistic treatment option for surgical and nonsurgical interventional specialists. Third, the device can be accurately placed and is retrievable prior to disengaging the deployment cable, in the event it does not fit or seal the PAU. Finally, if the occluder is
CASE REPORT KLEISLI AND WHEATLEY AMPLATZER OCCLUSION OF PENETRATING ULCER
e19
fully deployed, but it does not coapt with satisfaction, it is still possible to exclude the device and PAU with a covered stent graft. This approach has potential limitations. Long-term data is not yet available, and it is unclear whether this represents a durable repair. Furthermore, these devices are not designed to face aortic flow lumens, raising the question of whether the integrity of the device will be sustained. Similarly, it is unclear whether this device will prompt thrombotic or embolic events related to the surface area in the aortic lumen. We chose to keep this patient on 325 mg of daily aspirin, but do not know if additional agents are needed. In summary, we report the 12-month follow-up of a novel percutaneous technique for repair of a symptomatic PAU of the DTA. This may be a viable alternative for patients who are not candidates for endovascular repair secondary to poor vascular access or large aortic diameters. Potential advantages include decreased potential for paraplegia as a result of less coverage of intercostals arteries. Nevertheless, long-term follow-up and increased clinical experience is needed.
References 1. Shennan T. Dissecting aneurysms. In Medical Research Council, Special Report Series No. 193. London: HMSO, 1934. 2. Stanson AW, Kazmier FJ, Hollier LH, et al. Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann Vasc Surg 1986;1: 15–23. 3. Coady MA, Rizzo JA, Hammond GL, Pierce JG, Kopf GS, Elefteriades JA. Penetrating ulcer of the thoracic aorta: what is it? How do we recognize it? How do we manage it? J Vasc Surg 1998;27:1006 –15. 4. Brinster DR. Endovascular repair of the descending thoracic aorta for penetrating atherosclerotic ulcer disease. J Card Surg 2009;24:203– 8. 5. Hussain J, Strumpf R, Wheatley G, Diethrich E. Percutaneous closure of aortic pseudoaneurysm by Amplatzer occluder device-Case series of six patients. Catheter Cardiovasc Interv 2009;73:521–9. 6. Kannan BR, Jain AK, Qureshi SA, et al. Successful exclusion of large post-surgical pseudoaneurysms of the ascending aorta by a percutaneous approach. Ann Thorac Surg 2009;87: 1281– 4.
Symptomatic patients with penetrating atherosclerotic ulcers of the descending thoracic aorta have traditionally been treated by using an open surgical repair. The emergence of thoracic aortic stent-graft technologies has introduced a less invasive treatment option, which often involves covering excess portions of a normal aorta with stent-graft material. We describe the mid-term follow-up of a patient with a symptomatic penetrating atherosclerotic ulcer of the descending thoracic aorta treated with an Amplatzer septal occluder device (AGA Medical Corp, Plymouth, MN), which is typically used for structural heart disease. (Ann Thorac Surg 2009;88:e18 –9) © 2009 by The Society of Thoracic Surgeons
P
enetrating atherosclerotic ulcers (PAUs), along with intramural hematomas, represent focal aortic disease processes within the spectrum of acute aortic syndrome [1–3]. Both symptomatic patients with PAU and those with acute rupture have traditionally been treated with an open surgical repair. Recently, endovascular stent-grafting has emerged as a less-invasive treatment option [4]. However, with the latter approach, an excess amount of normal aorta proximal and distal to the excluded PAU is covered by stent-graft material to achieve suitable landing zones for the stent-graft. We describe a novel localized treatment option for a symptomatic patient with an expanding PAU of the descending thoracic aorta (DTA) using a 35-mm Amplatzer Cribriform Occluder (AGA Medical Corp, Plymouth, MN). A 60-year-old woman with hypertension and an 8-month history of symptomatic mid-back pain was referred for evaluation. Four years prior, she underwent successful repair of an acute type A aortic dissection along with surgical replacement of her aortic arch and proximal
Accepted for publication June 23, 2009. Address correspondence to Dr Wheatley, Arizona Heart Institute, 2632 N 20th St, Phoenix, AZ 85006; e-mail: [email protected].
DTA. A multi-slice computed tomographic (MSCT) scan revealed a dilated and ectatic DTA with no focal aortic deficits and no definitive source for her back pain. A repeat MSCT scan 3 months later for increased back pain demonstrated a new PAU (measuring 1.5 ⫻ 1.8 cm) in the mid-DTA, which was located well away from the prior surgical anastomosis in the proximal DTA. Her back pain was adequately controlled with pain medications and she remained hemodynamically stable. A follow-up MSCT scan performed 1 month later demonstrated an increase in size of the PAU to 2.3 ⫻ 2.8 cm (Figs 1A and 1B), with concomitant increase in the patient’s back pain, which became refractory to oral pain medications. Various treatment options were considered for her expanding, symptomatic PAU of the DTA, including open surgical repair and endovascular stent-grafting. The patient refused open surgical repair. The diameters of the DTA proximal and distal to the PAU were 42 mm, and at the time of her presentation, no approved thoracic aortic stent-graft was large enough in diameter to accommodate her DTA. Therefore we offered her percutaneous repair of the PAU using an Amplatzer septal occluder device (AGA Medical Corp). After obtaining informed consent, the patient was taken to the hybrid operating suite where percutaneous vascular access was obtained through the right common femoral artery. A thoracic aortogram demonstrated the PAU in the mid-DTA with a focal neck. Intravascular ultrasound confirmed the diagnosis as well, in addition to verifying that the diameters of the DTA were too large to accommodate commercially available stent-grafts at that time. We selectively engaged the PAU through a 9F sheath in the right common femoral artery and deployed the 35-mm Amplatzer Cribriform Occluder (AGA Medical Corp) into the PAU. One disk of the device was located within the PAU, whereas the other was in the flow lumen of the DTA. A completion angiogram demonstrated successful exclusion of the PAU with the occluder device. The vascular access site in the right groin was closed using an 8F Angioseal closure device (St. Jude Medical, St. Paul, MN). A MSCT scan on postoperative day 1 demonstrated adequate exclusion of the PAU. Her back pain resolved immediately after treatment, and she experienced an uneventful recovery. She was maintained on a full strength daily aspirin and MSCT scans at 6 months and 12 months postoperatively, which showed successful exclusion of the PAU without evidence of disk fracture or thrombus formation (Fig 1C).
Fig 1. (A, B) Preoperative multi-slice computed tomographic scan of the thoracic aorta reveals a PAU in the descending thoracic aorta (arrows). (C) Postoperative multi-slice computed tomographic scan of the descending thoracic aorta demonstrates successful deployment of the 35-mm Amplatzer Cribriform Occluder (arrow) (AGA Medical Corp, Plymouth, MN).
© 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/09/$36.00 doi:10.1016/j.athoracsur.2009.06.092
Ann Thorac Surg 2009;88:e18 –9
Comment With increased use of MSCT, an increasing number of aortic abnormalities are being identified, and our understanding of the development and progression of localized aortic diseases is improving. The PAU, a variant of acute aortic syndrome, was initially described in 1934 by Shennan [1], but this has only recently been acknowledged as a distinct pathologic variant of classic false lumen aortic dissection [2, 3]. Penetrating atherosclerotic ulcers are atherosclerotic lesions that ulcerate and disrupt the internal elastic lamina, leading to the development of a localized intramural hematoma due to erosion of aortic vasa vasorum by the ulcer. Potential added complications of PAU include pseudoaneurysm formation after breaking through the adventitia, progression to overt aortic dissection, or rupture in as many as 40% of patients [4]. Penetrating atherosclerotic ulcers frequently involve the DTA and are very uncommon in the ascending arch or abdominal aorta [3]. Differentiation of PAU from other causes of acute aortic syndrome, such as intramural hematoma and aortic dissection is difficult, as the clinical presentations of these diseases (ie, sudden onset of severe chest or back pain) may be very similar. In addition, PAU may have more chronic symptoms with chronic back pain unrelated to musculoskeletal disorders [3]. Previous reports have observed PAU in 2.3% to 11% of symptomatic patients with suspected acute aortic syndrome, but the actual incidence of PAU remains unknown [4]. This report describes the successful 12-month follow-up of a novel percutaneous treatment option for PAU of the DTA with an Amplatzer cccluder device. This approach offers several advantages [5, 6]. First, the risk of paraplegia after treatment could be significantly decreased as a result of minimal coverage of intercostal arteries, preserving spinal cord perfusion. Second, vascular access for this device is safely approached using percutaneous techniques and would avoid an incision in the groin, making it a realistic treatment option for surgical and nonsurgical interventional specialists. Third, the device can be accurately placed and is retrievable prior to disengaging the deployment cable, in the event it does not fit or seal the PAU. Finally, if the occluder is
CASE REPORT KLEISLI AND WHEATLEY AMPLATZER OCCLUSION OF PENETRATING ULCER
e19
fully deployed, but it does not coapt with satisfaction, it is still possible to exclude the device and PAU with a covered stent graft. This approach has potential limitations. Long-term data is not yet available, and it is unclear whether this represents a durable repair. Furthermore, these devices are not designed to face aortic flow lumens, raising the question of whether the integrity of the device will be sustained. Similarly, it is unclear whether this device will prompt thrombotic or embolic events related to the surface area in the aortic lumen. We chose to keep this patient on 325 mg of daily aspirin, but do not know if additional agents are needed. In summary, we report the 12-month follow-up of a novel percutaneous technique for repair of a symptomatic PAU of the DTA. This may be a viable alternative for patients who are not candidates for endovascular repair secondary to poor vascular access or large aortic diameters. Potential advantages include decreased potential for paraplegia as a result of less coverage of intercostals arteries. Nevertheless, long-term follow-up and increased clinical experience is needed.
References 1. Shennan T. Dissecting aneurysms. In Medical Research Council, Special Report Series No. 193. London: HMSO, 1934. 2. Stanson AW, Kazmier FJ, Hollier LH, et al. Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann Vasc Surg 1986;1: 15–23. 3. Coady MA, Rizzo JA, Hammond GL, Pierce JG, Kopf GS, Elefteriades JA. Penetrating ulcer of the thoracic aorta: what is it? How do we recognize it? How do we manage it? J Vasc Surg 1998;27:1006 –15. 4. Brinster DR. Endovascular repair of the descending thoracic aorta for penetrating atherosclerotic ulcer disease. J Card Surg 2009;24:203– 8. 5. Hussain J, Strumpf R, Wheatley G, Diethrich E. Percutaneous closure of aortic pseudoaneurysm by Amplatzer occluder device-Case series of six patients. Catheter Cardiovasc Interv 2009;73:521–9. 6. Kannan BR, Jain AK, Qureshi SA, et al. Successful exclusion of large post-surgical pseudoaneurysms of the ascending aorta by a percutaneous approach. Ann Thorac Surg 2009;87: 1281– 4.