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Endovascular Exclusion of Patch Aneurysms of Intercostal Arteries After Thoracoabdominal Aortic Aneurysm Repair
HOW TO DO IT
Endovascular Exclusion of Patch Aneurysms of Intercostal Arteries After Thoracoabdominal Aortic Aneurysm Repair Francis Juthier, MD, PhD, Natacha Rousse, MD, Carlo Banfi, MD, PhD, Jean-Paul Beregi, MD, PhD, André Vincentelli, MD, PhD, Alain Prat, MD, and Jean Bachet, MD Department of Cardiovascular Surgery, Centre Hospitalier Regional et Universitaire de Lille, Lille, France; Department of Radiology, Centre Hospitalier Universitaire Caremeau, Nîmes, France; and Department of Cardiovascular Surgery, Zahed Military Hospital, Abu Dhabi, United Arab Emirates
FEATURE ARTICLES
Reimplantation of the largest patent intercostal arteries is usually performed during thoracoabdominal aortic aneurysm repair. This may lead to aneurysmal evolution of the intercostal arteries patch. We report the successful percutaneous endovascular repair in 4 Marfan patients of aneurysms of the intercostal arteries patch that developed after thoracoabdominal aortic aneurysm repair (Crawford type II) during a mean delay of 70 months
(range, 48 to 91 months). All patients had previously undergone one or several aortic surgical procedures and had patent subclavian and hypogastric arterial networks. No in-hospital deaths or spinal cord ischemic injuries occurred, which emphasizes the importance of the vascular collateral network. (Ann Thorac Surg 2013;95:720 –2) © 2013 by The Society of Thoracic Surgeons
P
procedures performed in another center by one of us (J.B.). These 4 patients had resumed an active professional and social life and were very reluctant to undergo another risky reoperation. The mean delay between the TAAA replacement and the endovascular repair was 70 months (range, 48 to 91 months).
araplegia secondary to spinal cord ischemic injury (SCII) is one of the most feared complications after repair of descending thoracic aortic aneurysms (DTAAs) and thoracoabdominal aortic (TAA) aneurysms (TAAAs). Reimplantation of the largest patent intercostal arteries below the T7 to T8 level is generally performed during DTAA or TAAA operations and is believed to reduce the incidence of SCII [1, 2]. This leads to a potential risk of subsequent aneurysmal evolution of the intercostal arteries patch, especially in patients who have connective tissue disorders such as Marfan syndrome. Open operations and endovascular treatment have been proposed to address this specific complication [3]. We report our experience with percutaneous endovascular repair of intercostal arteries patch aneurysms after previous TAAA operations in patients with Marfan syndrome.
Technique Our Institutional Review Board approved this retrospective study and individual consent was not required.
Patient Characteristics From 2002 to 2008, 4 patients with Marfan syndrome underwent an endovascular treatment of patch aneurysms of intercostal arteries after a previous TAA replacement (Fig 1). Patients were aged between 41 and 52 years and had previously undergone 13 aortic surgical Accepted for publication Sept 24, 2012. Address correspondence to Dr Juthier, CHRU de Lille, Service de Chirurgie Cardiaque, hôpital Cardiologique, blvd du Pr Leclercq, 59037 Lille Cedex, France; e-mail: [email protected].
© 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
Endovascular Repair Technique All 4 patients underwent a preoperative angiographic computed tomography scan to plan the endovascular treatment and select the stent graft size. Procedures were performed with the patient under general anesthesia and monitoring with digital subtraction angiography and transesophageal echocardiography. A 50 U/kg intravenous bolus of heparin was given at the beginning of the procedure. The graft diameter was oversized by 10% to 15 % compared with the proximal and distal prosthetic landing zones. All the procedures were performed through a percutaneous transfemoral approach using the Perclose technique. Two 10F Prostar XL systems (Perclose Inc, Menlo Park, CA) were placed at 45° through the right common femoral artery, which was then progressively dilated to the size of the thoracic stent graft sheath (24F). The delivery system was inserted over a Lunderquist wire (Cook Medical, Bloomington, IN). The Valiant Thoraciq stent graft (Medtronic Cardiovascular, Santa Rosa, CA) was used in 2 patients, the Endofit stent graft (Lemaitre Vascular, Burlington, MA) in 1 patient, and the Zenith TX2 thoracic stent graft (Cook, Brisbane, Australia) in 1 patient. The endograft distal end was positioned just above the celiac axis. An additional balloon inflation of 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.09.058
Ann Thorac Surg 2013;95:720 –2
HOW TO DO IT JUTHIER ET AL INTERCOSTAL PATCH ANEURYSM EXCLUSION
721
the proximal and distal endograft stumps was necessary in patient 2 and a second stent graft was required proximally in patient 4 to completely exclude the patch aneurysm.
Results The endovascular procedure was successful in each patient, with complete exclusion of the aneurysm and absence of any endoleak (Fig 2). No in-hospital deaths, reoperations for bleeding, stroke, renal dysfunction, or SCII occurred. All 4 patients left the intensive care unit on postoperative day 1. A right femoral common artery false aneurysm developed in patient 4 that was successfully treated by iterative local compression. During a mean follow-up of 29.5 months (range, 19 to 42 months), there was no late death, recurrent intercostal patch aneurysm, or endograft infection.
Comment During the study period, 20 TAAAs in Marfan patients were done in our institution, with a mortality rate of 20% (4 patients). The incidence of the described aneurysm of the intercostal reimplantation patch was therefore ob-
served in 25% patients (4 of 16 survivors). Surprisingly, we did not observe any aortic aneurysm at the level of the visceral or renal arteries in these patients during followup, but the renal and visceral arteries were generally reimplanted in 2 separate patches. To our knowledge, the only other report that has been published on the incidence and management of intercostal arteries patch aneurysms after DTAA or TAAA was a recent study by Kulik and colleagues [3]. The repair consisted of open surgical replacement of the dilated aortic segment with the use of hypothermic circulatory arrest in 8 patients and in endovascular stent graft techniques in 3 patients. The authors concluded that both techniques were feasible. Nevertheless, the current policy in their institution is to prefer an endovascular approach when the aortic anatomy is suitable. The risk of patch aneurysm in the visceral or intercostal arteries has led several authors to propose separate reimplantation of the visceral and segmental arteries to limit the amount of native diseased aortic tissue exposed to systemic pressure [4]. These technical modifications are promising but increase the number of anastomoses and are extremely time-consuming. Another alternative proposed by Etz and coworkers [5] is represented by Fig 2. Postoperative (A) angiogram and (B) magnetic resonance imaging show satisfying endograft deployment (arrow) and complete exclusion of the aneurysm.
FEATURE ARTICLES
Fig 1. (A) A preoperative computed tomography axial section shows the patch aneurysm with a patent intercostal artery (arrow). (B) A preoperative angiogram shows the patch aneurysm (arrow).
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HOW TO DO IT JUTHIER ET AL INTERCOSTAL PATCH ANEURYSM EXCLUSION
FEATURE ARTICLES
direct aortic graft interposition, without preservation of the intercostal arteries. This technique and the “collateral network” principle on which it is based is certainly one of the most promising ways for preserving neurologic status and preventing the intercostal arteries reimplantation patch dilatation [6]. The use of stent grafts in patients with Marfan syndrome is usually contraindicated because the pathologic process affects the landing zones of the stent graft. But, in case of endovascular repair of a patch aneurysm after surgical DTAA or TAAA replacement, the landing zones are located inside the preexisting aortic graft and are resistant areas, thus limiting the risk of type I endoleaks. We did not observe any SCII complications in our patients after the endovascular exclusion of the intercostal arteries patch aneurysm, even though this procedure resulted in the sacrifice of all patent pairs of segmental arteries. The preserved integrity and patency of the internal iliac arteries, the left subclavian arteries, and both internal mammary arteries, as well as the staged nature of the total aortic replacement in all the patients, most probably allowed development of the collateral spinal cord flow supply. Furthermore, there were no intercostal arteries of more than 2 mm in diameter and no visible communication with the anterior spinal artery in our patients. This probably at least partly explains why our patients did not experience any SCII and reinforces the theory of Etz and colleagues [5] of the collateral network.
Ann Thorac Surg 2013;95:720 –2
Because aneurysmal dilatation of the segmental artery patch after reimplantation develops rapidly and unpredictably, “prophylactic stent grafting of the patch” could be an interesting and innovative strategy. Thoracic aortic stent grafting is, however, an invasive procedure that induces its own morbidity, and we would currently recommend waiting for the patch expansion rather than “prophylactic stent grafting.”
References 1. Safi HJ, Miller CC 3rd, Carr C, Iliopoulos DC, Dorsay DA, Baldwin JC. Importance of intercostal artery reattachment during thoracoabdominal aortic aneurysm repair. J Vasc Surg 1998;27:58 – 66; discussion: 66 – 8. 2. Crawford ES, Snyder DM, Cho GC, Roehm JO Jr. Progress in treatment of thoracoabdominal and abdominal aortic aneurysms involving celiac, superior mesenteric, and renal arteries. Ann Surg 1978;188:404 –22. 3. Kulik A, Allen BT, Kouchoukos NT. Incidence and management of intercostal patch aneurysms after repair of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2009; 138:352– 8. 4. Carrel TP, Signer C. Separate revascularization of the visceral arteries in thoracoabdominal aneurysm repair. Ann Thorac Surg 1999;68:573–5. 5. Etz CD, Halstead JC, Spielvogel, et al. Thoracic and thoracoabdominal aneurysm repair: is reimplantation of spinal cord arteries a waste of time? Ann Thorac Surg 2006;82:1670 –7. 6. Zoli S, Roder F, Etz CD, et al. Predicting the risk of paraplegia after thoracic and thoracoabdominal aneurysm repair. Ann Thorac Surg. 2010;90:1237– 44; discussion: 1245.
Endovascular Exclusion of Patch Aneurysms of Intercostal Arteries After Thoracoabdominal Aortic Aneurysm Repair Francis Juthier, MD, PhD, Natacha Rousse, MD, Carlo Banfi, MD, PhD, Jean-Paul Beregi, MD, PhD, André Vincentelli, MD, PhD, Alain Prat, MD, and Jean Bachet, MD Department of Cardiovascular Surgery, Centre Hospitalier Regional et Universitaire de Lille, Lille, France; Department of Radiology, Centre Hospitalier Universitaire Caremeau, Nîmes, France; and Department of Cardiovascular Surgery, Zahed Military Hospital, Abu Dhabi, United Arab Emirates
FEATURE ARTICLES
Reimplantation of the largest patent intercostal arteries is usually performed during thoracoabdominal aortic aneurysm repair. This may lead to aneurysmal evolution of the intercostal arteries patch. We report the successful percutaneous endovascular repair in 4 Marfan patients of aneurysms of the intercostal arteries patch that developed after thoracoabdominal aortic aneurysm repair (Crawford type II) during a mean delay of 70 months
(range, 48 to 91 months). All patients had previously undergone one or several aortic surgical procedures and had patent subclavian and hypogastric arterial networks. No in-hospital deaths or spinal cord ischemic injuries occurred, which emphasizes the importance of the vascular collateral network. (Ann Thorac Surg 2013;95:720 –2) © 2013 by The Society of Thoracic Surgeons
P
procedures performed in another center by one of us (J.B.). These 4 patients had resumed an active professional and social life and were very reluctant to undergo another risky reoperation. The mean delay between the TAAA replacement and the endovascular repair was 70 months (range, 48 to 91 months).
araplegia secondary to spinal cord ischemic injury (SCII) is one of the most feared complications after repair of descending thoracic aortic aneurysms (DTAAs) and thoracoabdominal aortic (TAA) aneurysms (TAAAs). Reimplantation of the largest patent intercostal arteries below the T7 to T8 level is generally performed during DTAA or TAAA operations and is believed to reduce the incidence of SCII [1, 2]. This leads to a potential risk of subsequent aneurysmal evolution of the intercostal arteries patch, especially in patients who have connective tissue disorders such as Marfan syndrome. Open operations and endovascular treatment have been proposed to address this specific complication [3]. We report our experience with percutaneous endovascular repair of intercostal arteries patch aneurysms after previous TAAA operations in patients with Marfan syndrome.
Technique Our Institutional Review Board approved this retrospective study and individual consent was not required.
Patient Characteristics From 2002 to 2008, 4 patients with Marfan syndrome underwent an endovascular treatment of patch aneurysms of intercostal arteries after a previous TAA replacement (Fig 1). Patients were aged between 41 and 52 years and had previously undergone 13 aortic surgical Accepted for publication Sept 24, 2012. Address correspondence to Dr Juthier, CHRU de Lille, Service de Chirurgie Cardiaque, hôpital Cardiologique, blvd du Pr Leclercq, 59037 Lille Cedex, France; e-mail: [email protected].
© 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
Endovascular Repair Technique All 4 patients underwent a preoperative angiographic computed tomography scan to plan the endovascular treatment and select the stent graft size. Procedures were performed with the patient under general anesthesia and monitoring with digital subtraction angiography and transesophageal echocardiography. A 50 U/kg intravenous bolus of heparin was given at the beginning of the procedure. The graft diameter was oversized by 10% to 15 % compared with the proximal and distal prosthetic landing zones. All the procedures were performed through a percutaneous transfemoral approach using the Perclose technique. Two 10F Prostar XL systems (Perclose Inc, Menlo Park, CA) were placed at 45° through the right common femoral artery, which was then progressively dilated to the size of the thoracic stent graft sheath (24F). The delivery system was inserted over a Lunderquist wire (Cook Medical, Bloomington, IN). The Valiant Thoraciq stent graft (Medtronic Cardiovascular, Santa Rosa, CA) was used in 2 patients, the Endofit stent graft (Lemaitre Vascular, Burlington, MA) in 1 patient, and the Zenith TX2 thoracic stent graft (Cook, Brisbane, Australia) in 1 patient. The endograft distal end was positioned just above the celiac axis. An additional balloon inflation of 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.09.058
Ann Thorac Surg 2013;95:720 –2
HOW TO DO IT JUTHIER ET AL INTERCOSTAL PATCH ANEURYSM EXCLUSION
721
the proximal and distal endograft stumps was necessary in patient 2 and a second stent graft was required proximally in patient 4 to completely exclude the patch aneurysm.
Results The endovascular procedure was successful in each patient, with complete exclusion of the aneurysm and absence of any endoleak (Fig 2). No in-hospital deaths, reoperations for bleeding, stroke, renal dysfunction, or SCII occurred. All 4 patients left the intensive care unit on postoperative day 1. A right femoral common artery false aneurysm developed in patient 4 that was successfully treated by iterative local compression. During a mean follow-up of 29.5 months (range, 19 to 42 months), there was no late death, recurrent intercostal patch aneurysm, or endograft infection.
Comment During the study period, 20 TAAAs in Marfan patients were done in our institution, with a mortality rate of 20% (4 patients). The incidence of the described aneurysm of the intercostal reimplantation patch was therefore ob-
served in 25% patients (4 of 16 survivors). Surprisingly, we did not observe any aortic aneurysm at the level of the visceral or renal arteries in these patients during followup, but the renal and visceral arteries were generally reimplanted in 2 separate patches. To our knowledge, the only other report that has been published on the incidence and management of intercostal arteries patch aneurysms after DTAA or TAAA was a recent study by Kulik and colleagues [3]. The repair consisted of open surgical replacement of the dilated aortic segment with the use of hypothermic circulatory arrest in 8 patients and in endovascular stent graft techniques in 3 patients. The authors concluded that both techniques were feasible. Nevertheless, the current policy in their institution is to prefer an endovascular approach when the aortic anatomy is suitable. The risk of patch aneurysm in the visceral or intercostal arteries has led several authors to propose separate reimplantation of the visceral and segmental arteries to limit the amount of native diseased aortic tissue exposed to systemic pressure [4]. These technical modifications are promising but increase the number of anastomoses and are extremely time-consuming. Another alternative proposed by Etz and coworkers [5] is represented by Fig 2. Postoperative (A) angiogram and (B) magnetic resonance imaging show satisfying endograft deployment (arrow) and complete exclusion of the aneurysm.
FEATURE ARTICLES
Fig 1. (A) A preoperative computed tomography axial section shows the patch aneurysm with a patent intercostal artery (arrow). (B) A preoperative angiogram shows the patch aneurysm (arrow).
722
HOW TO DO IT JUTHIER ET AL INTERCOSTAL PATCH ANEURYSM EXCLUSION
FEATURE ARTICLES
direct aortic graft interposition, without preservation of the intercostal arteries. This technique and the “collateral network” principle on which it is based is certainly one of the most promising ways for preserving neurologic status and preventing the intercostal arteries reimplantation patch dilatation [6]. The use of stent grafts in patients with Marfan syndrome is usually contraindicated because the pathologic process affects the landing zones of the stent graft. But, in case of endovascular repair of a patch aneurysm after surgical DTAA or TAAA replacement, the landing zones are located inside the preexisting aortic graft and are resistant areas, thus limiting the risk of type I endoleaks. We did not observe any SCII complications in our patients after the endovascular exclusion of the intercostal arteries patch aneurysm, even though this procedure resulted in the sacrifice of all patent pairs of segmental arteries. The preserved integrity and patency of the internal iliac arteries, the left subclavian arteries, and both internal mammary arteries, as well as the staged nature of the total aortic replacement in all the patients, most probably allowed development of the collateral spinal cord flow supply. Furthermore, there were no intercostal arteries of more than 2 mm in diameter and no visible communication with the anterior spinal artery in our patients. This probably at least partly explains why our patients did not experience any SCII and reinforces the theory of Etz and colleagues [5] of the collateral network.
Ann Thorac Surg 2013;95:720 –2
Because aneurysmal dilatation of the segmental artery patch after reimplantation develops rapidly and unpredictably, “prophylactic stent grafting of the patch” could be an interesting and innovative strategy. Thoracic aortic stent grafting is, however, an invasive procedure that induces its own morbidity, and we would currently recommend waiting for the patch expansion rather than “prophylactic stent grafting.”
References 1. Safi HJ, Miller CC 3rd, Carr C, Iliopoulos DC, Dorsay DA, Baldwin JC. Importance of intercostal artery reattachment during thoracoabdominal aortic aneurysm repair. J Vasc Surg 1998;27:58 – 66; discussion: 66 – 8. 2. Crawford ES, Snyder DM, Cho GC, Roehm JO Jr. Progress in treatment of thoracoabdominal and abdominal aortic aneurysms involving celiac, superior mesenteric, and renal arteries. Ann Surg 1978;188:404 –22. 3. Kulik A, Allen BT, Kouchoukos NT. Incidence and management of intercostal patch aneurysms after repair of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2009; 138:352– 8. 4. Carrel TP, Signer C. Separate revascularization of the visceral arteries in thoracoabdominal aneurysm repair. Ann Thorac Surg 1999;68:573–5. 5. Etz CD, Halstead JC, Spielvogel, et al. Thoracic and thoracoabdominal aneurysm repair: is reimplantation of spinal cord arteries a waste of time? Ann Thorac Surg 2006;82:1670 –7. 6. Zoli S, Roder F, Etz CD, et al. Predicting the risk of paraplegia after thoracic and thoracoabdominal aneurysm repair. Ann Thorac Surg. 2010;90:1237– 44; discussion: 1245.