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Endovascular Repair of a Traumatic Ascending Aortic Tear Injury
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Special Letters Section
a shorter time, as other authors confirmed (1). In previous reports, EVAS combined with the chimney technique was a preoperatively planned procedure, including elective (1,2) and urgent (3) procedures. All authors agreed that simultaneous ballooning of the chimney stent during endobag filling is essential to avoid compression of the vessel owing to the endobag itself. The cause of the inadvertent left renal artery coverage in this case is uncertain. The most likely cause is a slight upward shift of the device during the polymer injection; this could have determined a proximal migration of the device and almost complete coverage of the vessel ostium. Adu et al (4) summarized the available surgical and endovascular options in case of accidental renal artery coverage during standard EVAR. According to these authors, the chimney technique is the most suitable in cases of partial occlusion of the vessel ostium. In contrast to the cases cited by Adu et al (4), we immediately recognized the complication on completion angiography, and this allowed us to proceed directly to vessel cannulation and stent placement, which occurred 100 minutes later. In conclusion, we demonstrated that inadvertent aortic branch artery coverage after Nellix EVAS when recognized early can be successfully managed by immediate endobag aspiration and chimney placement before endobag refilling.
REFERENCES 1. Rouer M, El Batti S, Julia P, et al. Chimney stent graft for endovascular sealing of a pararenal aortic aneurysm. Ann Vasc Surg 2014; 28:1936.e15– 18. 2. Torella F, Chan TY, Shaikh U, et al. ChEVAS: combining suprarenal EVAS with chimney technique. Cardiovasc Intervent Radiol 2015; 38:1294–1298. 3. Truijers M, van Sterkenburg SM, Lardenoije JW, et al. Endovascular repair of a ruptured pararenal aortic aneurysm using the Nellix endovascular aneurysm sealing system and chimney grafts. J Endovasc Ther 2015; 22:291–294. 4. Adu J, Cheshire N, Riga CV, et al. Strategies to tackle unrecognized bilateral renal artery occlusion after endovascular aneurysm repair. Ann Vasc Surg 2012; 26:1127.e1–7.
Khashram et al
’
JVIR
Departments of Vascular Endovascular and Transplant Surgery (M.K., I.B., A.K.), Interventional Radiology (A.L.), and Cardiology (J.B.) Christchurch Hospital 2 Riccarton Avenue Christchurch 8011, New Zealand
Editor: Morbidity and mortality resulting from traumatic aortic injuries remain high despite the liberal use of endovascular therapy (1). Although the isthmus of the descending thoracic aorta is the most common site of injury, the entire arch may be affected. The institutional review board approved the preparation of this report. A 59-year-old man was involved in a motor vehicle accident and sustained multiple injuries with an associated Injury Severity Score of 50. A wholebody computed tomography (CT) scan showed an injury of the ascending aorta (grade II), splenic rupture, and fractures of the tibia and fibula (Fig 1). The patient was admitted to the intensive care unit, and systolic blood pressure was maintained at o 110 mm Hg systolic using intravenous β-blockers. A repeat CT angiogram on day 10 after injury showed progression of the aortic injury to a pseudoaneurysm (grade III) (Fig 2a). Because of his injuries, the patient was considered to have a high surgical risk for a conventional open aortic repair, and he was referred for endovascular treatment. The ascending aorta measured 26 mm in diameter and 60 mm from the sinotubular junction to the brachiocephalic artery. The pseudoaneurysm measured 26 mm 11 mm 14 mm and was 11 mm distal to the left coronary artery (Fig 2b). A multidisciplinary team including a cardiologist, interventional radiologists, and vascular surgeons performed the procedure. Under general anesthesia, a 6-F sheath was placed in the right femoral artery, and a 0.014-inch SION Blue (Asahi Intecc, Nagoya, Japan) wire with a 5-F Judkins left coronary catheter (Cordis Corporation, Miami Lakes,
Endovascular Repair of a Traumatic Ascending Aortic Tear Injury From: Manar Khashram, MBChB Irina Baimatova, MBChB Andrew Laing, MBChB, FRANZCR James Blake, MBChB, FRACP Adib Khanafer, MBBS, FRCS, FEBVS
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2016.07.025
Figure 1. Axial CT angiogram of the ascending aorta demonstrating the aortic injury (arrow) at the initial presentation (grade II).
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Figure 2. CT angiography demonstrating pseudoaneurysm formation (arrows, a and b) on day 10 after injury. Axial (a) and coronal (b) images.
Figure 3. Completion digital subtraction angiography of the ascending aorta demonstrating exclusion of the pseudoaneurysm and patency of the left (yellow arrow) and right (white arrow) coronary arteries.
Florida) was positioned in the left coronary artery. A second 6-F sheath was introduced into the right femoral vein for rapid right ventricular pacing. The right common carotid artery was surgically exposed, and a 10-F sheath was introduced. An angiogram from the carotid access confirmed the ascending aorta pseudoaneurysm. An Amplatz Super Stiff J-tip wire (Boston Scientific, Marlborough, Massachusetts) was passed into the left ventricle. The nose cone of the delivery system was trimmed with a blade. The 10-F sheath was removed, and the 20-F Zenith Main Body Extension (Cook, Inc, Bloomington, Indiana) was introduced via the carotid
Figure 4. Coronal CT angiogram after placement of endovascular stent graft.
artery to the level of the left coronary artery. To assist in graft positioning and accurate deployment, the coronary catheter acted as a landmark, and the position of the left coronary ostium was confirmed with injection of contrast material. Before the stent graft deployment, rapid pacing at 180 beats/min was induced to simulate near cardiac arrest. The Judkins left coronary catheter was pulled out leaving the 0.014-inch wire in the left coronary artery, and the stent graft was deployed. The completion angiogram confirmed adequate position of the graft and excluded the injury (Fig 3). The carotid arteriotomy was closed using a bovine pericardium patch (Synovis Life Technologies, St. Paul, Minnesota). A CT scan was performed on day 4 (Fig 4) and again at
1714
’
Special Letters Section
Zoethout et al
’
JVIR
knowledge, treatment of a traumatic ascending aortic pseudoaneurysm has not been previously described. More recently, off-the-shelf specific ascending aortic grafts are available to some centers, and preliminary results appear promising in selected patients who were turned down for conventional open surgery (4). In conclusion, a team approach using expertise from relevant specialties is valuable for such complex cases. Endovascular therapy can be a temporary or definitive measure in managing high-risk patients.
ACKNOWLEDGMENTS We thank Mr Shannon Collins, an Obex Medical Aortic Intervention (Auckland, New Zealand) representative, for his advice with this case.
REFERENCES Figure 5. Follow-up axial CT angiogram obtained 8 weeks after placement of endovascular stent graft.
8 weeks after the procedure (Fig 5) revealing a patent ascending aorta with complete resolution of the pseudoaneurysm. The postoperative course was uneventful, and there were no procedure-related complications. The length of hospital stay was 6 weeks for rehabilitation. On 5-month follow-up evaluation by telephone interview, the patient was clinically well and residing independently. He will remain on lifetime imaging surveillance for the stent graft. The challenges encountered in this case included the choice of an appropriate graft, access, and customizing the graft delivery system. The Zenith Main Body Extension was chosen because this stent graft has an anterior trigger wire. Therefore, it could be unsheathed and adjusted before final release. The right common carotid artery was chosen because it provided a short, relatively linear access to the injury site, facilitating stent graft positioning and precision in deployment. The delivery system had a 65-mm-long nose cone, which may carry a risk of myocardial perforation; therefore, it was trimmed and the end was tapered using a surgical scalpel. Blunt trauma injury of the ascending aorta is uncommon compared with injury of the descending thoracic aorta, as highlighted by a literature review that identified only 43 cases treated with immediate or delayed open surgery (2). Use of endovascular stent grafts in the management of ascending aorta lesions is emerging. The most common indications are postoperative residual dissection, pseudoaneurysms, and type A dissection in selected high-risk patients who had previous sternotomy (3). There are 4 100 cases reported in the literature of ascending aortic endografts, but, to our
1. Khashram M, He Q, Oh TH, et al. Late radiological and clinical outcomes of traumatic thoracic aortic injury managed with thoracic endovascular aortic repair. World J Surg 2016; 40:1763–1770. 2. Sun X, Hong J, Lowery R, et al. Ascending aortic injuries following blunt trauma. J Card Surg 2013; 28:749–755. 3. Roselli EE, Idrees J, Greenberg RK, Johnston DR, Lytle BW. Endovascular stent grafting for ascending aorta repair in high-risk patients. J Thorac Cardiovasc Surg 2015; 149:144–151. 4. Tsilimparis N, Debus ES, Oderich GS, et al. International experience with endovascular therapy of the ascending aorta with a dedicated endograft. J Vasc Surg 2016; 63:1476–1482.
Procedural Type Ia Endoleak during Endovascular Aneurysm Sealing Treated with a Second Sac Sealing Device From: Aleksandra C. Zoethout, BSc Michel M.P.J. Reijnen, MD, PhD Ignace F.J. Tielliu, MD, PhD Clark J. Zeebregts, MD, PhD Division of Vascular Surgery (A.C.Z., I.F.J.T., C.J.Z.) Department of Surgery University Medical Center Groningen University of Groningen PO Box 30 001 Groningen 9700 RB, The Netherlands; and Department of Surgery (M.M.P.J.R.) Rijnstate Hospital Arnhem, The Netherlands
M.M.P.J.R. is a paid consultant for and receives grants from Endologix, Inc (Irvine, California). None of the other authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2016.07.027
’
Special Letters Section
a shorter time, as other authors confirmed (1). In previous reports, EVAS combined with the chimney technique was a preoperatively planned procedure, including elective (1,2) and urgent (3) procedures. All authors agreed that simultaneous ballooning of the chimney stent during endobag filling is essential to avoid compression of the vessel owing to the endobag itself. The cause of the inadvertent left renal artery coverage in this case is uncertain. The most likely cause is a slight upward shift of the device during the polymer injection; this could have determined a proximal migration of the device and almost complete coverage of the vessel ostium. Adu et al (4) summarized the available surgical and endovascular options in case of accidental renal artery coverage during standard EVAR. According to these authors, the chimney technique is the most suitable in cases of partial occlusion of the vessel ostium. In contrast to the cases cited by Adu et al (4), we immediately recognized the complication on completion angiography, and this allowed us to proceed directly to vessel cannulation and stent placement, which occurred 100 minutes later. In conclusion, we demonstrated that inadvertent aortic branch artery coverage after Nellix EVAS when recognized early can be successfully managed by immediate endobag aspiration and chimney placement before endobag refilling.
REFERENCES 1. Rouer M, El Batti S, Julia P, et al. Chimney stent graft for endovascular sealing of a pararenal aortic aneurysm. Ann Vasc Surg 2014; 28:1936.e15– 18. 2. Torella F, Chan TY, Shaikh U, et al. ChEVAS: combining suprarenal EVAS with chimney technique. Cardiovasc Intervent Radiol 2015; 38:1294–1298. 3. Truijers M, van Sterkenburg SM, Lardenoije JW, et al. Endovascular repair of a ruptured pararenal aortic aneurysm using the Nellix endovascular aneurysm sealing system and chimney grafts. J Endovasc Ther 2015; 22:291–294. 4. Adu J, Cheshire N, Riga CV, et al. Strategies to tackle unrecognized bilateral renal artery occlusion after endovascular aneurysm repair. Ann Vasc Surg 2012; 26:1127.e1–7.
Khashram et al
’
JVIR
Departments of Vascular Endovascular and Transplant Surgery (M.K., I.B., A.K.), Interventional Radiology (A.L.), and Cardiology (J.B.) Christchurch Hospital 2 Riccarton Avenue Christchurch 8011, New Zealand
Editor: Morbidity and mortality resulting from traumatic aortic injuries remain high despite the liberal use of endovascular therapy (1). Although the isthmus of the descending thoracic aorta is the most common site of injury, the entire arch may be affected. The institutional review board approved the preparation of this report. A 59-year-old man was involved in a motor vehicle accident and sustained multiple injuries with an associated Injury Severity Score of 50. A wholebody computed tomography (CT) scan showed an injury of the ascending aorta (grade II), splenic rupture, and fractures of the tibia and fibula (Fig 1). The patient was admitted to the intensive care unit, and systolic blood pressure was maintained at o 110 mm Hg systolic using intravenous β-blockers. A repeat CT angiogram on day 10 after injury showed progression of the aortic injury to a pseudoaneurysm (grade III) (Fig 2a). Because of his injuries, the patient was considered to have a high surgical risk for a conventional open aortic repair, and he was referred for endovascular treatment. The ascending aorta measured 26 mm in diameter and 60 mm from the sinotubular junction to the brachiocephalic artery. The pseudoaneurysm measured 26 mm 11 mm 14 mm and was 11 mm distal to the left coronary artery (Fig 2b). A multidisciplinary team including a cardiologist, interventional radiologists, and vascular surgeons performed the procedure. Under general anesthesia, a 6-F sheath was placed in the right femoral artery, and a 0.014-inch SION Blue (Asahi Intecc, Nagoya, Japan) wire with a 5-F Judkins left coronary catheter (Cordis Corporation, Miami Lakes,
Endovascular Repair of a Traumatic Ascending Aortic Tear Injury From: Manar Khashram, MBChB Irina Baimatova, MBChB Andrew Laing, MBChB, FRANZCR James Blake, MBChB, FRACP Adib Khanafer, MBBS, FRCS, FEBVS
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2016.07.025
Figure 1. Axial CT angiogram of the ascending aorta demonstrating the aortic injury (arrow) at the initial presentation (grade II).
Volume 27
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Number 11
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November
’
2016
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Figure 2. CT angiography demonstrating pseudoaneurysm formation (arrows, a and b) on day 10 after injury. Axial (a) and coronal (b) images.
Figure 3. Completion digital subtraction angiography of the ascending aorta demonstrating exclusion of the pseudoaneurysm and patency of the left (yellow arrow) and right (white arrow) coronary arteries.
Florida) was positioned in the left coronary artery. A second 6-F sheath was introduced into the right femoral vein for rapid right ventricular pacing. The right common carotid artery was surgically exposed, and a 10-F sheath was introduced. An angiogram from the carotid access confirmed the ascending aorta pseudoaneurysm. An Amplatz Super Stiff J-tip wire (Boston Scientific, Marlborough, Massachusetts) was passed into the left ventricle. The nose cone of the delivery system was trimmed with a blade. The 10-F sheath was removed, and the 20-F Zenith Main Body Extension (Cook, Inc, Bloomington, Indiana) was introduced via the carotid
Figure 4. Coronal CT angiogram after placement of endovascular stent graft.
artery to the level of the left coronary artery. To assist in graft positioning and accurate deployment, the coronary catheter acted as a landmark, and the position of the left coronary ostium was confirmed with injection of contrast material. Before the stent graft deployment, rapid pacing at 180 beats/min was induced to simulate near cardiac arrest. The Judkins left coronary catheter was pulled out leaving the 0.014-inch wire in the left coronary artery, and the stent graft was deployed. The completion angiogram confirmed adequate position of the graft and excluded the injury (Fig 3). The carotid arteriotomy was closed using a bovine pericardium patch (Synovis Life Technologies, St. Paul, Minnesota). A CT scan was performed on day 4 (Fig 4) and again at
1714
’
Special Letters Section
Zoethout et al
’
JVIR
knowledge, treatment of a traumatic ascending aortic pseudoaneurysm has not been previously described. More recently, off-the-shelf specific ascending aortic grafts are available to some centers, and preliminary results appear promising in selected patients who were turned down for conventional open surgery (4). In conclusion, a team approach using expertise from relevant specialties is valuable for such complex cases. Endovascular therapy can be a temporary or definitive measure in managing high-risk patients.
ACKNOWLEDGMENTS We thank Mr Shannon Collins, an Obex Medical Aortic Intervention (Auckland, New Zealand) representative, for his advice with this case.
REFERENCES Figure 5. Follow-up axial CT angiogram obtained 8 weeks after placement of endovascular stent graft.
8 weeks after the procedure (Fig 5) revealing a patent ascending aorta with complete resolution of the pseudoaneurysm. The postoperative course was uneventful, and there were no procedure-related complications. The length of hospital stay was 6 weeks for rehabilitation. On 5-month follow-up evaluation by telephone interview, the patient was clinically well and residing independently. He will remain on lifetime imaging surveillance for the stent graft. The challenges encountered in this case included the choice of an appropriate graft, access, and customizing the graft delivery system. The Zenith Main Body Extension was chosen because this stent graft has an anterior trigger wire. Therefore, it could be unsheathed and adjusted before final release. The right common carotid artery was chosen because it provided a short, relatively linear access to the injury site, facilitating stent graft positioning and precision in deployment. The delivery system had a 65-mm-long nose cone, which may carry a risk of myocardial perforation; therefore, it was trimmed and the end was tapered using a surgical scalpel. Blunt trauma injury of the ascending aorta is uncommon compared with injury of the descending thoracic aorta, as highlighted by a literature review that identified only 43 cases treated with immediate or delayed open surgery (2). Use of endovascular stent grafts in the management of ascending aorta lesions is emerging. The most common indications are postoperative residual dissection, pseudoaneurysms, and type A dissection in selected high-risk patients who had previous sternotomy (3). There are 4 100 cases reported in the literature of ascending aortic endografts, but, to our
1. Khashram M, He Q, Oh TH, et al. Late radiological and clinical outcomes of traumatic thoracic aortic injury managed with thoracic endovascular aortic repair. World J Surg 2016; 40:1763–1770. 2. Sun X, Hong J, Lowery R, et al. Ascending aortic injuries following blunt trauma. J Card Surg 2013; 28:749–755. 3. Roselli EE, Idrees J, Greenberg RK, Johnston DR, Lytle BW. Endovascular stent grafting for ascending aorta repair in high-risk patients. J Thorac Cardiovasc Surg 2015; 149:144–151. 4. Tsilimparis N, Debus ES, Oderich GS, et al. International experience with endovascular therapy of the ascending aorta with a dedicated endograft. J Vasc Surg 2016; 63:1476–1482.
Procedural Type Ia Endoleak during Endovascular Aneurysm Sealing Treated with a Second Sac Sealing Device From: Aleksandra C. Zoethout, BSc Michel M.P.J. Reijnen, MD, PhD Ignace F.J. Tielliu, MD, PhD Clark J. Zeebregts, MD, PhD Division of Vascular Surgery (A.C.Z., I.F.J.T., C.J.Z.) Department of Surgery University Medical Center Groningen University of Groningen PO Box 30 001 Groningen 9700 RB, The Netherlands; and Department of Surgery (M.M.P.J.R.) Rijnstate Hospital Arnhem, The Netherlands
M.M.P.J.R. is a paid consultant for and receives grants from Endologix, Inc (Irvine, California). None of the other authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2016.07.027