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Endovascular Management of Radiotherapy-Induced Injury to Brachiocephalic Artery Using Covered Stents
Endovascular Management of Radiotherapy-Induced Injury to Brachiocephalic Artery Using Covered Stents Noelia Maria Cenizo, Jose A. Gonzalez-Fajardo, Maria A. Ibanez, Victoria Gastambide, Miguel Martin-Pedrosa, Vicente Gutierrez, James Taylor, and Carlos Vaquero, Valladolid, Spain
Actinic vascular lesions tend to be stenotic-occlusive lesions. In this article, we present 2 exceptional cases of pseudoaneurysms caused by radionecrosis of the supra-aortic trunks. Both patients were treated by a retrograde carotid approach and deployment of a self-expanding covered stent. Proper exclusion of the pseudoaneurysm was attained in both cases; the first patient remained asymptomatic 12 months later; the second patient died of mediastinitis. Compared with conventional surgery, endovascular management is a viable, less invasive alternative in select patients, especially in life-threatening cases.
CASE 1 A 75-year-old woman was admitted with a bleeding lesion due to a radiotherapy-induced ulcer of the upper left hemithorax. She had a history of left breast cancer treated with mastectomy and radiotherapy 36 years before. Examination of the ulcer bed showed a hematoma that was the result of recent bleeding. Surrounding tissues presented with highgrade of fibrosis. The left clavicle was exposed and showed significant radionecrosis. She also had paresis of her left arm caused by a brachial plexus neuritis. Intraoperative angiography through a right common femoral artery puncture revealed active bleeding at the origin of the innominate artery (Fig. 1A). The distal common carotid artery (CCA) was chosen as the access route. Because of the
Hospital Clinico Universitario de Valladolid, Valladolid, Spain. Correspondence to: Noelia Maria Cenizo, Angiologı´a y Cirugı´a Vascular, Hospital Clinico Universitario de Valladolid, Avda. Ramon y Cajal 3, 47003 Valladolid, Spain; E-mail: [email protected] Ann Vasc Surg 2014; 28: 741.e15–741.e18 http://dx.doi.org/10.1016/j.avsg.2013.10.004 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: January 2, 2013; manuscript accepted: October 2, 2013.
patient’s life-threatening condition, surgical control of the right CCA was made under general anesthesia; a 12F sheath was placed through retrograde puncture of the artery. A hydrophilic 180-cm (0.035 inch) guidewire (Radiofocus, Terumo, Leuven, Belgium) was passed through the lesion and into the aortic arch; it was then exchanged for a stiffer wire, an Amplatz-Super-Stiff (180 cm [0.035 in.], Boston Scientific, Miami, FL) using a diagnostic catheter (IMAGER, Boston Scientific, 5F, Natick, MA). A Wallgraft endoprosthesis (12 50 mm, Boston Scientific Corporation, Galway, Ireland) was then deployed from the origin of the innominate artery and distally, covering the arterial rupture completely and also from the origin of the right subclavian artery (RSA). A final arteriogram showed no active bleeding and retrograde enhancement of the RSA through collateral circulation. The patient displayed a warm right extremity but no pulses (Fig. 1B). She was given 5000 units of heparin intraoperatively and discharged 5 days later with double antiplatelet therapy for 3 months, followed by aspirin 100 mg per day indefinitely. A follow-up computed tomography (CT) 19 months later showed correct endoprosthesis position and sealing of the lesion (Fig. 1C). The right arm remained asymptomatic. A consultation with the 741.e15
741.e16 Case reports
Fig. 1. (A) Intraoperative angiography showing active bleeding at the innominate artery origin (arrow). (B) Final arteriogram demonstrates no active bleeding and
Annals of Vascular Surgery
retrograde enhancement of RSA through collaterals. (C) Follow-up CT 19 months later showing a correct endoprosthesis position and sealing of the lesion.
plastic surgery department was made; flaps commonly used to reconstruct the anterior chest could not be used, and therefore, amputation of nonfunctional left upper limb was needed to cover the skin defect. The ulcer had essentially healed on the first follow-up visit at 3 months.1
CASE 2 A 71-year-old woman presented to the emergency department with a bleeding lesion at the level of the suprasternal notch due to a radiotherapyinduced ulcer. Twenty-seven years earlier, she underwent surgery for thyroid cancer and received postoperative radiotherapy. A chest CT showed a pseudoaneurysm of the innominate artery origin (3 4 cm) connected to the overlying skin through a cutaneous fistula, manubrium sterni radionecrosis, and RSA thrombosis (Fig. 2A). We deployed a Wallgraft endoprosthesis (14 70 mm) using a right CCA open access, covering the origin of the pseudoaneurysm and the ostium of RSA, which was already thrombosed because of radiation. Angiographic control showed complete exclusion of the pseudoaneurysm (Fig. 2B). The thoracic surgeon was consulted, and because of the patient’s highrisk characteristics (i.e., severe chronic obstructive pulmonary disease, cor pulmonale, right phrenic paralysis), aggressive surgical treatment of the mediastinitis was not recommended. The patient received local treatment for the ulcer and antibiotic treatment empirically before the cultures were collected with piperacillin/tazobactam (4/0.5 g intravenously/every 8 hours). Cultures of the ulcer grew Enterobacter cloacae, which is susceptible to the antibiotic used. This bacteria was also susceptible to sulfamehtoxazole/trimethoprim, which was
Fig. 2. (A) Preoperative CT showing a pseudoaneurysm of innominate artery origin. (B) Angiographic control showing complete exclusion of the pseudoaneurysm sac. (C) Control CT showing air bubbles in the mediastinum.
prescribed as oral treatment when the patient was discharged (800/160 mg/every 12 hours for at least for 3 months). Unfortunately, 2 months later, she returned to the hospital with worsening of the ulcerated area. The new CT showed no endoleak but
Vol. 28, No. 3, April 2014
did reveal air bubbles in the mediastinum, and the patient eventually died of recurrent mediastinitis (Fig. 2C).
DISCUSSION Injury to large vessels after radiotherapy are uncommon. The most common pathophysiologic mechanism is accelerated atherosclerosis, but aneurysmal dilatation is also possible due to damage to the elastic layers of the arterial wall. Vessel perforation is extremely rare. Ischemic injury and periadventitial fibrosis may contribute to rupture of the artery. Proximity to an open ulcer can also lead to infection of the arterial wall and perforation.2,3 Other mechanisms of damage could be spontaneous tissue necrosis and disintegration of underlying vascular layers,4 or vessel trauma due to pathologic fracture caused by osteitis/osteomyelitis secondary to radiation. The most frequent affected arteries are subclavian or axillary arteries,1,3 but there are reported cases of affectation of the ascending aorta or carotid arteries.2,5 To our knowledge, however, these are the first reported cases of involvement of the innominate trunk. The surgical management of this injury requires a median sternotomy with extension of the incision into the supraclavicular space. Irradiation causes damage of the neighboring tissues and severe fibrosis. These changes result in many technical problems during surgery and subsequent vascular reconstruction, increasing morbidity and mortality rates.2,6 Results of endovascular treatment in the supraaortic trunk area have been promising. The most extensive experience with covered stents has been in the carotid arteries to treat pseudoaneurysms or arteriovenous fistulas. Follow-up of these studies was diverse, ranging from a few days to approximately 36 months. Most of the studies reported no stenosis or thrombosis of the stents. In addition, the few occlusions reported were asymptomatic.7,8 Because of the urgent nature of the cases reported here, immediately available stents had to be used, and the most adequate selection from our stock were used. Unfortunately, the disadvantage of some covered stents is that they have less navigability compared with fenestrated stents. Some stents are also of limited use because the delivery catheter length is not sufficient to reach the brachiocephalic artery from the femoral arteries, and manipulation of large sheaths through the aortic arch can be dangerous.2,9 In our opinion, these concerns made the direct
Case reports 741.e17
retrograde carotid approach the best choice to treat these patients with the available stents. Moreover, this approach minimizes the risk of cerebral embolization.9 In both cases, the device was deployed from the right CCA to the innominate artery, across the RSA. No symptoms of ischemia appeared in the right upper extremity; therefore, a bypass to the arm was not necessary as it has been in other published cases.10 It is likely that an auto-expandable polytetrafluoroethylene stent (e.g., Viabahn), which has more traction capacity, would have allowed a femoral approach. Likewise, if a shorter balloonexpandable stent had been available, a more precise deployment would have been possible, and the subclavian artery would have been spared.11 An advantage of self-expanding devices is that they are less likely to rupture and collapse.7 Nevertheless, their deployment is less precise than other options.12 With this approach, it is important to make an exact measurement of the length of the area that must be covered, select the appropriate stent, and perform a careful deployment. Double antiplatelet therapy for 3 months and aspirin alone indefinitely thereafter is recommended after these procedures.2,7,8 The possibility of infection as a complication of radionecrosis lesions increases preoperative and postoperative risks and results in worse outcomes. Nevertheless, there are published cases of descending aortic mycotic pseudoaneurysms treated with endoprosthesis with good results.13,14 A 48-hour antibiotic treatment before the intervention would have been optimal in these cases to prevent an infection of the prosthesis, but the active bleeding prompted for an immediate intervention.
CONCLUSION These 2 cases demonstrate that radiation injury to soft tissues may extend to deeper layers and damage vascular structures long after treatment. This lifethreatening lesion can be treated successfully with endovascular devices and may reduce the high morbidity and mortality typically associated with innominate trunk access, which is aggravated by an extremely fibrotic field. However, long-term patency and durability of the treatment remains unknown. REFERENCES 1. Har-Shay Y, Schein M, Molek A, et al. Ruptured mycotic aneurysm of the subclavian artery after irradiation. Eur J Surg 1993;159:59e60.
741.e18 Case reports
2. Ellens DJ, Hurley M, Surdel D, et al. Radiotherapy-induced common carotid pseudoaneurysm presenting with initially occult upper airway hemorrhage and successfully treated by endovascular stent graft. Am J Otolaryngol 2010;31:195e8. 3. Ewings EL, Wittgen C, Paletta CE. Prolonged success with a covered endovascular stent after emergent use in radiationinduced subclavian artery blowout: a case report. Vasc Endovasc Surg 2008;42:187e91. 4. Urayama H, Fukui D, Iijima S, et al. A case of axillary arterial bleeding caused by radiation-induced chest wall ulcer after radiotherapy for carcinoma of the breast: extraanatomic bypass grafting for upper limb salvage. Surgey 1998;12: 480e2. 5. Venissac N, Pop D, Mouroux J. Ascending aortic rupture behind a sterna radionecrosis for breast cancer. NZJ Surg 2007;77:496. 6. Maruyama Y, Arai K, Hoshida S, et al. Case of three delayed complications of radiotherapy: bilateral vocal cord immobility, esophageal obstruction and ruptured pseudoaneurysm of carotid artery. Auris Nasus Larynx 2009;36:505e8. 7. Sch€ onholz CJ, Uflacker R, De Gregorio MA, et al. Stent-graft treatment of trauma to the supra-aortic arteries. J Cariovasc Surg 2007;48:537e49.
Annals of Vascular Surgery
8. Tiewei Q, Ali A, Shaolei G, et al. Carotid cavernous fistulas treated by endovascular covered stent grafts with followup results. Br J Neurosurg 2010;24:435e40. 9. Ahuja V, Tefera G. Successful covered stent-graft exclusi on of carotid artery pseudoaneurysm: two case reports and review of literature. Ann Vasc Surg 2007;21:367e72. 10. Huang C, Kao H. Endovascular management of posttraumatic innominate artery transaction with pseudoaneurysm formation. Catheter Cardiovasc Interv 2008;71: 569e72. 11. Hagspiel KD, Komorowski D, Shih MP, et al. Treatment of carotid arteriovenous fistula with balloon-expandable tracheobronchial covered stent. J Vasc Interv Radiol 2006;17:585e6. 12. Gifford SM, Deel JT, Dent DL, et al. Endovascular repair of innominate artery injury secondary to air rifle pellet: a case report and review. Vasc Endovasc Surg 2009;43:301e5. 13. Vaughan-Huxley E, Hamady M, Metcalfe MJ, et al. Endovascular repair of an acute, mycotic, ascending aortic pseudoaneurysm. Eur J Vasc Endovasc Surg 2011;41:488e91. 14. Martin-Pedrosa M, Cenizo N, Gutierrez V. Endovascular therapy of ascending thoracic aorta. Ann Vasc Surg 2010; 24:696e8.
Actinic vascular lesions tend to be stenotic-occlusive lesions. In this article, we present 2 exceptional cases of pseudoaneurysms caused by radionecrosis of the supra-aortic trunks. Both patients were treated by a retrograde carotid approach and deployment of a self-expanding covered stent. Proper exclusion of the pseudoaneurysm was attained in both cases; the first patient remained asymptomatic 12 months later; the second patient died of mediastinitis. Compared with conventional surgery, endovascular management is a viable, less invasive alternative in select patients, especially in life-threatening cases.
CASE 1 A 75-year-old woman was admitted with a bleeding lesion due to a radiotherapy-induced ulcer of the upper left hemithorax. She had a history of left breast cancer treated with mastectomy and radiotherapy 36 years before. Examination of the ulcer bed showed a hematoma that was the result of recent bleeding. Surrounding tissues presented with highgrade of fibrosis. The left clavicle was exposed and showed significant radionecrosis. She also had paresis of her left arm caused by a brachial plexus neuritis. Intraoperative angiography through a right common femoral artery puncture revealed active bleeding at the origin of the innominate artery (Fig. 1A). The distal common carotid artery (CCA) was chosen as the access route. Because of the
Hospital Clinico Universitario de Valladolid, Valladolid, Spain. Correspondence to: Noelia Maria Cenizo, Angiologı´a y Cirugı´a Vascular, Hospital Clinico Universitario de Valladolid, Avda. Ramon y Cajal 3, 47003 Valladolid, Spain; E-mail: [email protected] Ann Vasc Surg 2014; 28: 741.e15–741.e18 http://dx.doi.org/10.1016/j.avsg.2013.10.004 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: January 2, 2013; manuscript accepted: October 2, 2013.
patient’s life-threatening condition, surgical control of the right CCA was made under general anesthesia; a 12F sheath was placed through retrograde puncture of the artery. A hydrophilic 180-cm (0.035 inch) guidewire (Radiofocus, Terumo, Leuven, Belgium) was passed through the lesion and into the aortic arch; it was then exchanged for a stiffer wire, an Amplatz-Super-Stiff (180 cm [0.035 in.], Boston Scientific, Miami, FL) using a diagnostic catheter (IMAGER, Boston Scientific, 5F, Natick, MA). A Wallgraft endoprosthesis (12 50 mm, Boston Scientific Corporation, Galway, Ireland) was then deployed from the origin of the innominate artery and distally, covering the arterial rupture completely and also from the origin of the right subclavian artery (RSA). A final arteriogram showed no active bleeding and retrograde enhancement of the RSA through collateral circulation. The patient displayed a warm right extremity but no pulses (Fig. 1B). She was given 5000 units of heparin intraoperatively and discharged 5 days later with double antiplatelet therapy for 3 months, followed by aspirin 100 mg per day indefinitely. A follow-up computed tomography (CT) 19 months later showed correct endoprosthesis position and sealing of the lesion (Fig. 1C). The right arm remained asymptomatic. A consultation with the 741.e15
741.e16 Case reports
Fig. 1. (A) Intraoperative angiography showing active bleeding at the innominate artery origin (arrow). (B) Final arteriogram demonstrates no active bleeding and
Annals of Vascular Surgery
retrograde enhancement of RSA through collaterals. (C) Follow-up CT 19 months later showing a correct endoprosthesis position and sealing of the lesion.
plastic surgery department was made; flaps commonly used to reconstruct the anterior chest could not be used, and therefore, amputation of nonfunctional left upper limb was needed to cover the skin defect. The ulcer had essentially healed on the first follow-up visit at 3 months.1
CASE 2 A 71-year-old woman presented to the emergency department with a bleeding lesion at the level of the suprasternal notch due to a radiotherapyinduced ulcer. Twenty-seven years earlier, she underwent surgery for thyroid cancer and received postoperative radiotherapy. A chest CT showed a pseudoaneurysm of the innominate artery origin (3 4 cm) connected to the overlying skin through a cutaneous fistula, manubrium sterni radionecrosis, and RSA thrombosis (Fig. 2A). We deployed a Wallgraft endoprosthesis (14 70 mm) using a right CCA open access, covering the origin of the pseudoaneurysm and the ostium of RSA, which was already thrombosed because of radiation. Angiographic control showed complete exclusion of the pseudoaneurysm (Fig. 2B). The thoracic surgeon was consulted, and because of the patient’s highrisk characteristics (i.e., severe chronic obstructive pulmonary disease, cor pulmonale, right phrenic paralysis), aggressive surgical treatment of the mediastinitis was not recommended. The patient received local treatment for the ulcer and antibiotic treatment empirically before the cultures were collected with piperacillin/tazobactam (4/0.5 g intravenously/every 8 hours). Cultures of the ulcer grew Enterobacter cloacae, which is susceptible to the antibiotic used. This bacteria was also susceptible to sulfamehtoxazole/trimethoprim, which was
Fig. 2. (A) Preoperative CT showing a pseudoaneurysm of innominate artery origin. (B) Angiographic control showing complete exclusion of the pseudoaneurysm sac. (C) Control CT showing air bubbles in the mediastinum.
prescribed as oral treatment when the patient was discharged (800/160 mg/every 12 hours for at least for 3 months). Unfortunately, 2 months later, she returned to the hospital with worsening of the ulcerated area. The new CT showed no endoleak but
Vol. 28, No. 3, April 2014
did reveal air bubbles in the mediastinum, and the patient eventually died of recurrent mediastinitis (Fig. 2C).
DISCUSSION Injury to large vessels after radiotherapy are uncommon. The most common pathophysiologic mechanism is accelerated atherosclerosis, but aneurysmal dilatation is also possible due to damage to the elastic layers of the arterial wall. Vessel perforation is extremely rare. Ischemic injury and periadventitial fibrosis may contribute to rupture of the artery. Proximity to an open ulcer can also lead to infection of the arterial wall and perforation.2,3 Other mechanisms of damage could be spontaneous tissue necrosis and disintegration of underlying vascular layers,4 or vessel trauma due to pathologic fracture caused by osteitis/osteomyelitis secondary to radiation. The most frequent affected arteries are subclavian or axillary arteries,1,3 but there are reported cases of affectation of the ascending aorta or carotid arteries.2,5 To our knowledge, however, these are the first reported cases of involvement of the innominate trunk. The surgical management of this injury requires a median sternotomy with extension of the incision into the supraclavicular space. Irradiation causes damage of the neighboring tissues and severe fibrosis. These changes result in many technical problems during surgery and subsequent vascular reconstruction, increasing morbidity and mortality rates.2,6 Results of endovascular treatment in the supraaortic trunk area have been promising. The most extensive experience with covered stents has been in the carotid arteries to treat pseudoaneurysms or arteriovenous fistulas. Follow-up of these studies was diverse, ranging from a few days to approximately 36 months. Most of the studies reported no stenosis or thrombosis of the stents. In addition, the few occlusions reported were asymptomatic.7,8 Because of the urgent nature of the cases reported here, immediately available stents had to be used, and the most adequate selection from our stock were used. Unfortunately, the disadvantage of some covered stents is that they have less navigability compared with fenestrated stents. Some stents are also of limited use because the delivery catheter length is not sufficient to reach the brachiocephalic artery from the femoral arteries, and manipulation of large sheaths through the aortic arch can be dangerous.2,9 In our opinion, these concerns made the direct
Case reports 741.e17
retrograde carotid approach the best choice to treat these patients with the available stents. Moreover, this approach minimizes the risk of cerebral embolization.9 In both cases, the device was deployed from the right CCA to the innominate artery, across the RSA. No symptoms of ischemia appeared in the right upper extremity; therefore, a bypass to the arm was not necessary as it has been in other published cases.10 It is likely that an auto-expandable polytetrafluoroethylene stent (e.g., Viabahn), which has more traction capacity, would have allowed a femoral approach. Likewise, if a shorter balloonexpandable stent had been available, a more precise deployment would have been possible, and the subclavian artery would have been spared.11 An advantage of self-expanding devices is that they are less likely to rupture and collapse.7 Nevertheless, their deployment is less precise than other options.12 With this approach, it is important to make an exact measurement of the length of the area that must be covered, select the appropriate stent, and perform a careful deployment. Double antiplatelet therapy for 3 months and aspirin alone indefinitely thereafter is recommended after these procedures.2,7,8 The possibility of infection as a complication of radionecrosis lesions increases preoperative and postoperative risks and results in worse outcomes. Nevertheless, there are published cases of descending aortic mycotic pseudoaneurysms treated with endoprosthesis with good results.13,14 A 48-hour antibiotic treatment before the intervention would have been optimal in these cases to prevent an infection of the prosthesis, but the active bleeding prompted for an immediate intervention.
CONCLUSION These 2 cases demonstrate that radiation injury to soft tissues may extend to deeper layers and damage vascular structures long after treatment. This lifethreatening lesion can be treated successfully with endovascular devices and may reduce the high morbidity and mortality typically associated with innominate trunk access, which is aggravated by an extremely fibrotic field. However, long-term patency and durability of the treatment remains unknown. REFERENCES 1. Har-Shay Y, Schein M, Molek A, et al. Ruptured mycotic aneurysm of the subclavian artery after irradiation. Eur J Surg 1993;159:59e60.
741.e18 Case reports
2. Ellens DJ, Hurley M, Surdel D, et al. Radiotherapy-induced common carotid pseudoaneurysm presenting with initially occult upper airway hemorrhage and successfully treated by endovascular stent graft. Am J Otolaryngol 2010;31:195e8. 3. Ewings EL, Wittgen C, Paletta CE. Prolonged success with a covered endovascular stent after emergent use in radiationinduced subclavian artery blowout: a case report. Vasc Endovasc Surg 2008;42:187e91. 4. Urayama H, Fukui D, Iijima S, et al. A case of axillary arterial bleeding caused by radiation-induced chest wall ulcer after radiotherapy for carcinoma of the breast: extraanatomic bypass grafting for upper limb salvage. Surgey 1998;12: 480e2. 5. Venissac N, Pop D, Mouroux J. Ascending aortic rupture behind a sterna radionecrosis for breast cancer. NZJ Surg 2007;77:496. 6. Maruyama Y, Arai K, Hoshida S, et al. Case of three delayed complications of radiotherapy: bilateral vocal cord immobility, esophageal obstruction and ruptured pseudoaneurysm of carotid artery. Auris Nasus Larynx 2009;36:505e8. 7. Sch€ onholz CJ, Uflacker R, De Gregorio MA, et al. Stent-graft treatment of trauma to the supra-aortic arteries. J Cariovasc Surg 2007;48:537e49.
Annals of Vascular Surgery
8. Tiewei Q, Ali A, Shaolei G, et al. Carotid cavernous fistulas treated by endovascular covered stent grafts with followup results. Br J Neurosurg 2010;24:435e40. 9. Ahuja V, Tefera G. Successful covered stent-graft exclusi on of carotid artery pseudoaneurysm: two case reports and review of literature. Ann Vasc Surg 2007;21:367e72. 10. Huang C, Kao H. Endovascular management of posttraumatic innominate artery transaction with pseudoaneurysm formation. Catheter Cardiovasc Interv 2008;71: 569e72. 11. Hagspiel KD, Komorowski D, Shih MP, et al. Treatment of carotid arteriovenous fistula with balloon-expandable tracheobronchial covered stent. J Vasc Interv Radiol 2006;17:585e6. 12. Gifford SM, Deel JT, Dent DL, et al. Endovascular repair of innominate artery injury secondary to air rifle pellet: a case report and review. Vasc Endovasc Surg 2009;43:301e5. 13. Vaughan-Huxley E, Hamady M, Metcalfe MJ, et al. Endovascular repair of an acute, mycotic, ascending aortic pseudoaneurysm. Eur J Vasc Endovasc Surg 2011;41:488e91. 14. Martin-Pedrosa M, Cenizo N, Gutierrez V. Endovascular therapy of ascending thoracic aorta. Ann Vasc Surg 2010; 24:696e8.