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Complication tardive d’un stentgraft thoracique
Cas clinique Complication tardive d’un stentgraft thoracique Omar Al-Nouri,1 Carl Moeller,2 Richard Borrowdale,2 Ross Milner,3 Maywood, Illinois, USA
paration endovasculaire aortique thoracique (TEVAR) est devenue de plus en plus popuLa re vrysmes aortiques thoraciques descendants. En de pit de son laire pour le traitement des ane et de sa se curite , plusieurs complications peuvent se produire avec TEVAR. Nous rapefficacite s TEVAR lie e a la portons un cas d’une femme de 76 ans avec une complication tardive apre cidive d’un cancer thyroı¨dien et a une revascularisation carotido-sous-clavie re. re
Thoracic aortic aneurysms have been estimated to affect 10 of every 100,000 elderly adults, with 30-40% of these being descending thoracic aortic aneurysms (DTAs).1 The former mainstay of surgical management of DTAs has been open thoracic aneurysm repair. Despite the use of extracorporeal circulation and cerebral spinal fluid monitoring, morbidity and mortality in this age group exceeds 50-70%.2 Over the past 10 years, endovascular treatment of DTAs has steadily increased and is now becoming the standard method of repair. One comparative study between traditional open repairs versus thoracic endovascular aortic repair (TEVAR) showed a perioperative mortality rate of 11.7% versus 2.1%, respectively.3 Despite the improved safety and efficacy of TEVAR, several well known complications exist, including endoleak, stroke, renal failure, spinal cord ischemia, and stent migration. An important issue in expanding TEVAR utilization is coverage of the left subclavian artery (LSA). DOI of original article: 10.1016/j.avsg.2011.02.039. 1 2
Department of Surgery, Loyola University, Maywood, IL, USA. Department of Otolaryngology, Loyola University, Maywood, IL, USA.
3 Department of Vascular Surgery and Endovascular Therapy, Loyola University, Maywood, IL, USA.
Correspondance : Omar Al-Nouri, Department of Surgery, Loyola University, 2160 S. First Avenue, Maywood, IL 60153, USA, E-mail: [email protected] Ann Vasc Surg 2011; 25: 982.e1-982.e4 http://dx.doi.org/10.1016/j.acvfr.2012.10.007 Ó Annals of Vascular Surgery Inc. e par ELSEVIER MASSON SAS Edit
The need for subclavian artery revascularization has been controversial in most circumstances. In this article, we report a late complication of TEVAR related to a prophylactic carotidesubclavian artery prosthetic bypass.
CASE REPORT A 76-year-old woman with remote history of TEVAR (2004) with placement of stentegraft across the LSA requiring carotidesubclavian bypass with polytetrafluoroethylene presented with a recurrent left neck mass. The patient had previously undergone a total thyroidectomy, left selective neck dissection, and radioactive iodine therapy in 2007 for papillary thyroid carcinoma. Her current work-up included routine laboratory studies, a fine-needle aspiration biopsy of the left neck mass, and computed tomographic scanning of the neck. Fine-needle aspiration biopsy confirmed recurrent metastatic papillary cancer with hurthle cell features. The computed tomographic scan of the neck revealed an ill-defined left supraclavicular mass with circumferential involvement of the left carotid to subclavian bypass as well as significant left cervical lymphadenopathy (Fig. 1). Planning a radical neck dissection, the otolaryngology service obtained a vascular surgery consultation. A balloon occlusion test of the left internal carotid artery (ICA) was performed by interventional neuroradiology before resection (Fig. 2). Occlusion of the left ICA did not produce any neurologic changes or cerebral perfusion deficits, and demonstrated good cross-filling of the right ICA. In addition, the patient had widely patent left vertebral artery proximal to the surgical bypass. The patient was taken to the operating room by the otolaryngology and vascular surgery services. After 1046.e5
1046.e6 Cas cliniques
Fig. 1. Computed tomographic scan of the neck without contrast showing ill-defined mass with (white arrow) circumferential involvement of left subclavian to carotid bypass. exposure, vascular control of the left ICA and the bypass graft was obtained. The bypass graft was then clamped directly on the common carotid artery and the graft was then transected. The common carotid artery was repaired with use of a 3-0 prolene suture. Next, the tumor was completely resected and the distal end of the bypass was transected. The subclavian artery was repaired with a 3-0 prolene suture. The left arm was examined after graft resection and there was a strong radial and ulnar Doppler signal. A decision was made intraoperatively that she would not require any further vascular reconstruction. She regained consciousness in the operating room and was neurologically intact. She did well in the recovery period. She had no left arm symptoms and developed a palpable left radial artery pulse.
DISCUSSION Treatment of DTAs by endovascular techniques depends on obtaining an adequate proximal landing zone. Extension of the stentegraft proximally to cover the LSA to achieve an adequate proximal landing zone is sometimes necessary. The TEVAR literature divides the thoracic aorta into five proximal landing zones, zones 0-4 (Fig. 3). LSA coverage because of thoracic stentegraft extension into zone 2 is an interesting dilemma for the treating vascular surgeon. In the previously published data, two treatment strategies exist for coverage of LSA. One involves routine preoperative revascularization of the LSA with transposition or bypass from the carotid artery to avoid the potential for ischemic complications. The second approach involves selective revascularization of the LSA based on estimating the risk of ischemic complications.4 Recently, a study by Buth et al.5 from the European Collaborators on Stent/
Annales de chirurgie vasculaire
Graft Techniques for Aortic Aneurysm Repair registry reported a significant fourfold increase risk of postoperative paraplegia with LSA coverage without revascularization. This finding, however, has been challenged by a recent study by Kotelis et al.,6 which found that the risk of paraplegia or stroke associated with intentional LSA coverage may be overestimated. In their study, 88 of 220 patients (40%) had thoracic aortic lesions that required endograft deployment covering the origin of the LSA. Primary LSA revascularization occurred in 22 of those 88 patients. Unlike the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair registry (40% paraplegia rate for LSA coverage), LSA coverage without revascularization was only associated with a 1.1% paraplegia rate. Risk of stroke is also a concern when covering the LSA. Peterson et al.7 showed high complication rates when covering the LSA without revascularization, 63% complication rate, with a stroke rate of 50%. However, Kotelis et al.6 did not reproduce similar findings, as their stroke rate was only 3%. There continues to be much debate regarding the adverse effects of placing a thoracic stentegraft across the orifice of the LSA. Perfusion to the spine, brain, and left arm may be compromised when the LSA is covered, leading to an increased risk of paraplegia, stroke, and subclavian steal syndrome. Generally speaking, coverage of the LSA may be well tolerated because there is an extensive network of rich collaterals to provide spinal, brain, chest, and arm perfusion. However, not all patients have such a rich network of collaterals and such patients are mostly at higher risk. Several risk factors for development of ischemic complications owing to coverage of LSA have been well documented. Using a selective approach to LSA revascularization, given the conflicting data, may be the best approach to minimize the perioperative risk involved. Risk factors include atretic or absent right subclavian artery, patent left axillary-femoral bypass graft, isolated posterior circulation, dominant left vertebral artery, functioning left arm arteriovenous dialysis access, hypoplastic right vertebral artery, and patent left internal mammary artery (LIMA) to left anterior descending artery coronary bypass (LAD) graft. Type II endoleaks may occur with coverage of LSA because of backfilling of the aneurysm through patent subclavian artery; LSA revascularization with subclavian artery transposition or ligation of the proximal subclavian artery can decrease the risk of type II endoleaks.8 In our patient, who had LSA revascularization after TEVAR that was complicated by a recurrent thyroid malignancy extending into close proximity
Vol. 25, No. 7, 2011
Cas cliniques 1046.e7
Fig. 2. Cerebral angiogram with balloon occlusion testing showing patent (white arrow) left carotidesubclavian bypass and patent (black arrows) left vertebral artery.
Fig. 3. The proximal landing zones of the thoracic aorta. Zone 0 is defined as the ascending aorta, which covers all the arch vessels. Zone 1 includes coverage of left carotid and subclavian arteries. Zone 2 covers the left subclavian artery. Zone 3 is the descending aorta down to the level of T4. Zone 4 is the descending aorta from T4 level to diaphragm.
of the bypass graft, to achieve adequate resection margin, the bypass was resected. The patient did undergo preoperative balloon occlusion testing to determine her risk of stroke and other symptoms in case she required removal of the bypass graft.
The patient tolerated balloon occlusion and angiography showed bilateral patent vertebral artery with a nonisolated posterior circulation, indicating that the patient would be at low risk for ischemic complications if the bypass graft was removed. Cerebral angiography with balloon occlusion, either preoperatively or intraoperatively, may be considered to determine ischemic complications when coverage of the LSA is needed for adequate sealing of DTAs with thoracic endograft. This may minimize the risk of performing LSA revascularization in a patient who might not need it. Alternatively, fenestrated or branched endovascular stentegrafts that are currently being evaluated in clinical trials could significantly minimize the risk of ischemic complications when zone 2 coverage of a thoracic endovascular stentegraft is needed. Another option to maintain antegrade perfusion to the LSA is by use of the snorkel technique. A covered or uncovered peripheral stent can be deployed extending from the subclavian artery to the proximal edge of the aortic endograft. This creates a gap between the aortic wall and the endograft, allowing for antegrade flow. The risk of endoleak with this technique is minimal and early results in published case series show 100% branch vessel patency.8,9 Limitations to the use of snorkel technique is the unintentional coverage of other arch vessels, namely the innominate and left common carotid arteries. REFERENCES 1. Black JH. Thoracic and thoracoabdominal aortic aneurysms. In: Cameron JL ed. Current Surgical Therapy. 9th ed. Philadelphia, PA: Mosby Elsevier, 2008. pp 753-760.
1046.e8 Cas cliniques
2. Huynh TTT, Miller CC, Estrera AE, Porat EE, Safi HJ. Thoracoabdominal and descending thoracic aortic aneurysm surgery in patients aged 79 years or older. J Vasc Surg 2002;36:469-475. 3. Bavaria JE, Appoo JJ, Makaroun MS, Verter J, Yu ZF, 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. 4. Reece TB, Gazoni LM, Cherry KJ, et coll. Reevaluating the need for left subclavian artery revascularization with thoracic endovascular aortic repair. Ann Thorac Surg 2007;84:1201-1205. 5. Buth J, Harris PL, Hobo R, et coll. Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm
Annales de chirurgie vasculaire
6.
7.
8. 9.
Repair (EUROSTAR) registry. J Vasc Surg 2007;46: 1103-1110. Kotelis D, Geisb€ usch P, Hinz U, et coll. Short and midterm results after left subclavian artery coverage during endovascular repair of the thoracic aorta. J Vasc Surg 2009;50: 1285-1292. Peterson BG, Eskandari M, Gleason T, Morasch M. Utility of left subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology. J Vasc Surg 2006;43:433-449. Feezor RJ, Lee WA. Management of the left subclavian artery during TEVAR. Semin Vasc Surg 2009;22:159-164. Bladwin ZK, Chuter TA, Hiramoto JS, Reilly LM, Schneider DB. Double-barrel technique for preservation of aortic arch branches during thoracic endovascular aortic repair. Ann Vasc Surg 2008;22:703-709.
paration endovasculaire aortique thoracique (TEVAR) est devenue de plus en plus popuLa re vrysmes aortiques thoraciques descendants. En de pit de son laire pour le traitement des ane et de sa se curite , plusieurs complications peuvent se produire avec TEVAR. Nous rapefficacite s TEVAR lie e a la portons un cas d’une femme de 76 ans avec une complication tardive apre cidive d’un cancer thyroı¨dien et a une revascularisation carotido-sous-clavie re. re
Thoracic aortic aneurysms have been estimated to affect 10 of every 100,000 elderly adults, with 30-40% of these being descending thoracic aortic aneurysms (DTAs).1 The former mainstay of surgical management of DTAs has been open thoracic aneurysm repair. Despite the use of extracorporeal circulation and cerebral spinal fluid monitoring, morbidity and mortality in this age group exceeds 50-70%.2 Over the past 10 years, endovascular treatment of DTAs has steadily increased and is now becoming the standard method of repair. One comparative study between traditional open repairs versus thoracic endovascular aortic repair (TEVAR) showed a perioperative mortality rate of 11.7% versus 2.1%, respectively.3 Despite the improved safety and efficacy of TEVAR, several well known complications exist, including endoleak, stroke, renal failure, spinal cord ischemia, and stent migration. An important issue in expanding TEVAR utilization is coverage of the left subclavian artery (LSA). DOI of original article: 10.1016/j.avsg.2011.02.039. 1 2
Department of Surgery, Loyola University, Maywood, IL, USA. Department of Otolaryngology, Loyola University, Maywood, IL, USA.
3 Department of Vascular Surgery and Endovascular Therapy, Loyola University, Maywood, IL, USA.
Correspondance : Omar Al-Nouri, Department of Surgery, Loyola University, 2160 S. First Avenue, Maywood, IL 60153, USA, E-mail: [email protected] Ann Vasc Surg 2011; 25: 982.e1-982.e4 http://dx.doi.org/10.1016/j.acvfr.2012.10.007 Ó Annals of Vascular Surgery Inc. e par ELSEVIER MASSON SAS Edit
The need for subclavian artery revascularization has been controversial in most circumstances. In this article, we report a late complication of TEVAR related to a prophylactic carotidesubclavian artery prosthetic bypass.
CASE REPORT A 76-year-old woman with remote history of TEVAR (2004) with placement of stentegraft across the LSA requiring carotidesubclavian bypass with polytetrafluoroethylene presented with a recurrent left neck mass. The patient had previously undergone a total thyroidectomy, left selective neck dissection, and radioactive iodine therapy in 2007 for papillary thyroid carcinoma. Her current work-up included routine laboratory studies, a fine-needle aspiration biopsy of the left neck mass, and computed tomographic scanning of the neck. Fine-needle aspiration biopsy confirmed recurrent metastatic papillary cancer with hurthle cell features. The computed tomographic scan of the neck revealed an ill-defined left supraclavicular mass with circumferential involvement of the left carotid to subclavian bypass as well as significant left cervical lymphadenopathy (Fig. 1). Planning a radical neck dissection, the otolaryngology service obtained a vascular surgery consultation. A balloon occlusion test of the left internal carotid artery (ICA) was performed by interventional neuroradiology before resection (Fig. 2). Occlusion of the left ICA did not produce any neurologic changes or cerebral perfusion deficits, and demonstrated good cross-filling of the right ICA. In addition, the patient had widely patent left vertebral artery proximal to the surgical bypass. The patient was taken to the operating room by the otolaryngology and vascular surgery services. After 1046.e5
1046.e6 Cas cliniques
Fig. 1. Computed tomographic scan of the neck without contrast showing ill-defined mass with (white arrow) circumferential involvement of left subclavian to carotid bypass. exposure, vascular control of the left ICA and the bypass graft was obtained. The bypass graft was then clamped directly on the common carotid artery and the graft was then transected. The common carotid artery was repaired with use of a 3-0 prolene suture. Next, the tumor was completely resected and the distal end of the bypass was transected. The subclavian artery was repaired with a 3-0 prolene suture. The left arm was examined after graft resection and there was a strong radial and ulnar Doppler signal. A decision was made intraoperatively that she would not require any further vascular reconstruction. She regained consciousness in the operating room and was neurologically intact. She did well in the recovery period. She had no left arm symptoms and developed a palpable left radial artery pulse.
DISCUSSION Treatment of DTAs by endovascular techniques depends on obtaining an adequate proximal landing zone. Extension of the stentegraft proximally to cover the LSA to achieve an adequate proximal landing zone is sometimes necessary. The TEVAR literature divides the thoracic aorta into five proximal landing zones, zones 0-4 (Fig. 3). LSA coverage because of thoracic stentegraft extension into zone 2 is an interesting dilemma for the treating vascular surgeon. In the previously published data, two treatment strategies exist for coverage of LSA. One involves routine preoperative revascularization of the LSA with transposition or bypass from the carotid artery to avoid the potential for ischemic complications. The second approach involves selective revascularization of the LSA based on estimating the risk of ischemic complications.4 Recently, a study by Buth et al.5 from the European Collaborators on Stent/
Annales de chirurgie vasculaire
Graft Techniques for Aortic Aneurysm Repair registry reported a significant fourfold increase risk of postoperative paraplegia with LSA coverage without revascularization. This finding, however, has been challenged by a recent study by Kotelis et al.,6 which found that the risk of paraplegia or stroke associated with intentional LSA coverage may be overestimated. In their study, 88 of 220 patients (40%) had thoracic aortic lesions that required endograft deployment covering the origin of the LSA. Primary LSA revascularization occurred in 22 of those 88 patients. Unlike the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair registry (40% paraplegia rate for LSA coverage), LSA coverage without revascularization was only associated with a 1.1% paraplegia rate. Risk of stroke is also a concern when covering the LSA. Peterson et al.7 showed high complication rates when covering the LSA without revascularization, 63% complication rate, with a stroke rate of 50%. However, Kotelis et al.6 did not reproduce similar findings, as their stroke rate was only 3%. There continues to be much debate regarding the adverse effects of placing a thoracic stentegraft across the orifice of the LSA. Perfusion to the spine, brain, and left arm may be compromised when the LSA is covered, leading to an increased risk of paraplegia, stroke, and subclavian steal syndrome. Generally speaking, coverage of the LSA may be well tolerated because there is an extensive network of rich collaterals to provide spinal, brain, chest, and arm perfusion. However, not all patients have such a rich network of collaterals and such patients are mostly at higher risk. Several risk factors for development of ischemic complications owing to coverage of LSA have been well documented. Using a selective approach to LSA revascularization, given the conflicting data, may be the best approach to minimize the perioperative risk involved. Risk factors include atretic or absent right subclavian artery, patent left axillary-femoral bypass graft, isolated posterior circulation, dominant left vertebral artery, functioning left arm arteriovenous dialysis access, hypoplastic right vertebral artery, and patent left internal mammary artery (LIMA) to left anterior descending artery coronary bypass (LAD) graft. Type II endoleaks may occur with coverage of LSA because of backfilling of the aneurysm through patent subclavian artery; LSA revascularization with subclavian artery transposition or ligation of the proximal subclavian artery can decrease the risk of type II endoleaks.8 In our patient, who had LSA revascularization after TEVAR that was complicated by a recurrent thyroid malignancy extending into close proximity
Vol. 25, No. 7, 2011
Cas cliniques 1046.e7
Fig. 2. Cerebral angiogram with balloon occlusion testing showing patent (white arrow) left carotidesubclavian bypass and patent (black arrows) left vertebral artery.
Fig. 3. The proximal landing zones of the thoracic aorta. Zone 0 is defined as the ascending aorta, which covers all the arch vessels. Zone 1 includes coverage of left carotid and subclavian arteries. Zone 2 covers the left subclavian artery. Zone 3 is the descending aorta down to the level of T4. Zone 4 is the descending aorta from T4 level to diaphragm.
of the bypass graft, to achieve adequate resection margin, the bypass was resected. The patient did undergo preoperative balloon occlusion testing to determine her risk of stroke and other symptoms in case she required removal of the bypass graft.
The patient tolerated balloon occlusion and angiography showed bilateral patent vertebral artery with a nonisolated posterior circulation, indicating that the patient would be at low risk for ischemic complications if the bypass graft was removed. Cerebral angiography with balloon occlusion, either preoperatively or intraoperatively, may be considered to determine ischemic complications when coverage of the LSA is needed for adequate sealing of DTAs with thoracic endograft. This may minimize the risk of performing LSA revascularization in a patient who might not need it. Alternatively, fenestrated or branched endovascular stentegrafts that are currently being evaluated in clinical trials could significantly minimize the risk of ischemic complications when zone 2 coverage of a thoracic endovascular stentegraft is needed. Another option to maintain antegrade perfusion to the LSA is by use of the snorkel technique. A covered or uncovered peripheral stent can be deployed extending from the subclavian artery to the proximal edge of the aortic endograft. This creates a gap between the aortic wall and the endograft, allowing for antegrade flow. The risk of endoleak with this technique is minimal and early results in published case series show 100% branch vessel patency.8,9 Limitations to the use of snorkel technique is the unintentional coverage of other arch vessels, namely the innominate and left common carotid arteries. REFERENCES 1. Black JH. Thoracic and thoracoabdominal aortic aneurysms. In: Cameron JL ed. Current Surgical Therapy. 9th ed. Philadelphia, PA: Mosby Elsevier, 2008. pp 753-760.
1046.e8 Cas cliniques
2. Huynh TTT, Miller CC, Estrera AE, Porat EE, Safi HJ. Thoracoabdominal and descending thoracic aortic aneurysm surgery in patients aged 79 years or older. J Vasc Surg 2002;36:469-475. 3. Bavaria JE, Appoo JJ, Makaroun MS, Verter J, Yu ZF, 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. 4. Reece TB, Gazoni LM, Cherry KJ, et coll. Reevaluating the need for left subclavian artery revascularization with thoracic endovascular aortic repair. Ann Thorac Surg 2007;84:1201-1205. 5. Buth J, Harris PL, Hobo R, et coll. Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm
Annales de chirurgie vasculaire
6.
7.
8. 9.
Repair (EUROSTAR) registry. J Vasc Surg 2007;46: 1103-1110. Kotelis D, Geisb€ usch P, Hinz U, et coll. Short and midterm results after left subclavian artery coverage during endovascular repair of the thoracic aorta. J Vasc Surg 2009;50: 1285-1292. Peterson BG, Eskandari M, Gleason T, Morasch M. Utility of left subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology. J Vasc Surg 2006;43:433-449. Feezor RJ, Lee WA. Management of the left subclavian artery during TEVAR. Semin Vasc Surg 2009;22:159-164. Bladwin ZK, Chuter TA, Hiramoto JS, Reilly LM, Schneider DB. Double-barrel technique for preservation of aortic arch branches during thoracic endovascular aortic repair. Ann Vasc Surg 2008;22:703-709.