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Endovascular Stent-graft Placement for Retrograde Type A Aortic Dissection
Volume 22 䡲 Number 3 䡲 March 䡲 2011
ties of the visceral parent arteries. The only means to preserve the patency of the parent artery in these cases is to perform superselective arterial embolization by three-dimensional coil packing of the PA sac with use of controlled detachable microcoils placed in a concentric fashion, possibly in combination with an injection of Onyx embolic agent. We recently reported excellent results with this technique regardless of the clinical presentation, cause, or location of the lesion at the level of major peripheral or visceral arterial branches (4). We suggest that this conservative therapeutic option may deserve to be used whenever possible, as it preserves the patency of the parent artery. In conclusion, our experience suggests that transcatheter embolization with NBCA in well trained hands is effective and safe in patients with distal PAs, and does not cause more ischemic complications than other embolic agents if used cautiously. Conversely, glue embolization should absolutely not be attempted for PAs located at the level of major peripheral or visceral arteries.
REFERENCES 1. Song HH, Won YD, Kim YJ. Transcatheter N-butyl cyanoacrylate embolization of pseudoaneurysms. J Vasc Interv Radiol 2010; 21:1508 –1511. 2. Loffroy R, Guiu B, Cercueil JP, et al. Transcatheter arterial embolization of splenic artery aneurysms and pseudoaneurysms: short- and long-term results. Ann Vasc Surg 2008; 22:618 – 626. 3. Tokuda T, Tanigawa N, Shomura Y, et al. Transcatheter embolization for peripheral pseudoaneurysms with n-butyl cyanoacrylate. Minim Invasive Ther Allied Technol 2009; 18:361–365. 4. Loffroy R, Rao P, Ota S, et al. Packing technique for endovascular coil embolisation of peripheral arterial pseudo-aneurysms with preservation of the parent artery: safety, efficacy and outcomes. Eur J Vasc Endovasc Surg 2010; 40:209 –215.
Endovascular Stent-graft Placement for Retrograde Type A Aortic Dissection From: Jianjun Jiang, MD Xiangjiu Ding, MD Guangyong Zhang, MD Sanyuan Hu, MD Qingbo Su, MD Feng Li, MD Department of Vascular Surgery Qilu Hospital Shandong University 107 Wenhua Xi Road Jinan, 250012, P. R. China
Editor: Stanford type A aortic dissection is a life-threatening disease with a 50% risk of death within the first 48 hours. Descending thoracic aortic dissection extending into the ascending aorta is a special subgroup of type A dissection,
None of the authors have identified a conflict of interest. DOI: 10.1016/j.jvir.2010.11.019
415
which usually requires extensive aortic replacement. The surgical outcomes have improved with the development of surgical techniques and anesthesia, but the operative mortality rate is still high. Recently, combined surgical and endovascular treatment has been used for retrograde type A aortic dissection. Herein, we present a total endovascular stent-graft repair for type A aortic dissection with an entry tear in the descending aorta. We believe this to be a promising alternative to surgical graft replacement. A 57-year-old man with a history of hypertension presented with severe chest and abdominal pain. Blood pressure at admission was 190/110 mm Hg. The patient’s pain was refractory to pethidine hydrochloride. Computed tomographic (CT) angiography revealed a type A aortic dissection with an entry tear in the descending aorta. The descending aortic dissection retrogradely extended into the ascending aorta (Figure, a). The distance between the tear and the left subclavian artery was 10 mm. The diameter of the true lumen immediately proximal to the tear was 26 mm. Another entry tear was identified in the abdominal aorta and extended into the right iliac artery (Figure, b). The patient refused surgical graft replacement. Endovascular treatment was considered and informed consent was signed. Emergency endovascular repair was performed under general anesthesia. A left femoral arteriotomy was performed after intravenous administration of heparin (100 U/kg). Aortography confirmed the CT angiography findings. Cerebral angiography displayed that bilateral carotid arteries, vertebral artery, and circle of Willis were unobstructed. The left common carotid artery and the left subclavian artery were marked on the screen. A 32 ⫻ 150 mm Talent covered stent (Medtronic, Minneapolis, Minnesota) was selected. The diagnostic catheter was exchanged for the delivery system over a super-stiff guide wire (Lunderquist Extra Stiff; Cook, Bloomington, Indiana). When the top end of the endograft reached the left common carotid artery, the stent-graft was deployed by pulling back the sheath. Subsequent aortography showed the tear and the left subclavian artery were completely covered (Figure, c). No endoleak was observed. The arteriotomy site was sutured after sheath removal. The patient recovered successfully without limb ischemia. The abdominal aortic entry tear, untreated at the time of thoracic endograft placement, remained at 3-month follow-up; the patient was asymptomatic. CT revealed patency of the stent-graft with no endoleak. The thrombosed false lumen in the ascending aorta had obviously shrunk, and the true lumen had enlarged (Figure, d). More and more patients with type A dissection are managed by endovascular stent-graft repair (1–3), but there are still several issues to consider. There is still a controversy concerning the proper treatment. The standard approach for type A dissection is ascending aortic replacement, but many distal complications cannot be treated simultaneously. Although extended aortic replacement can
416 䡲 Letters to the Editor
Jiang et al 䡲 JVIR
Figure. (a) Preoperative CT scan with multiplanar reconstruction. The false lumen is thrombosed in the ascending and proximal descending aorta (stars). (b) Intraoperative angiogram shows the abdominal aorta separated into two lumens. The false lumen is patent (star). (c) Intraoperative aortogram after stent-graft placement reveals the orifice of the left subclavian artery is covered. The left common carotid artery (arrow) is patent. (d) CT image with maximum-intensity projection at 3-month follow-up shows that the true lumen in the ascending aorta has enlarged and the false lumen has shrunk.
manage the ascending and descending aortic pathologic processes together, the operative mortality rate is still high. Von Segesser proposed it should be managed in accordance with the site of the predominant lesion (4). In 2003, Jazayeri combined interventional graft placement and surgical repair to treat retrograde type A dissection (5). We agree with the viewpoint of Von Segesser and performed endovascular repair in our patient. The main objective of endovascular repair is not to eliminate the blood flow in the false lumen, but to seal the tears, restore the blood flow in the true lumen, relieve distal malperfusion, and prevent aortic rupture. Several cases of successful endovascular stent-graft repair of retrograde type A dissection have been reported (2,3,6). Endovascular stent-graft repair for acute aortic dissection is debated because the aortic wall is usually thin and
fragile (3). In the majority of reported cases (including the current case), repair was performed in the acute stage. In the reviewed reports, no significant complications have been reported. To obtain an adequate seal, the left subclavian artery is often covered with or without revascularization. Previous reports suggest that coverage of the left subclavian artery is generally safe and well tolerated (7). In the current case, the left vertebral artery was dominant, but the left subclavian artery was covered uneventfully without reconstruction. In conclusion, endovascular stent-graft repair was clinically successful, without complications, in this case. The safety and effectiveness as well as the longer-term results of this technique need to be confirmed by further studies.
Volume 22 䡲 Number 3 䡲 March 䡲 2011
REFERENCES 1. Park KB, Do YS, Kim SS, Kim DK, Choe YH. Endovascular treatment of acute complicated aortic dissection: long-term follow-up of clinical outcomes and CT findings. J Vasc Interv Radiol 2009; 20:334 –341. 2. Shimono T, Kato N, Tokui T, et al. Endovascular stent-graft repair for acute type a aortic dissection with an intimal tear in the descending aorta. J Thorac Cardiovasc Surg 1998; 116:171–173. 3. Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 1999; 340:1546 –1552. 4. von Segesser LK, Killer I, Ziswiler M, et al. Dissection of the descending thoracic aorta extending into the ascending aorta. A therapeutic challenge. J thorac Cardiovasc Surg 1994; 108:755–761. 5. Jazayeri S, Tatou E, Gomez MC, et al. Combined treatment of aortic type A dissection: ascending aorta repair and placement of a stent in the descending aorta. Heart Surg Forum 2003; 6:387–389. 6. Kato N, Shimono T, Hirano T, Ishida M, Yada I, Takeda K. Transluminal placement of endovascular stent-grafts for the treatment of type A aortic dissection with an entry tear in the descending thoracic aorta. J Vasc Surg 2001; 34:1023–1028. 7. Noor N, Sadat U, Hayes PD, Thompson MM, Boyle JR. Management of the left subclavian artery during endovascular repair of the thoracic aorta. J Endovasc Ther 2008; 15:168 –176.
Emergency Endovascular Repair of Two Ascending Aortic Pseudoaneurysms From: Pierfrancesco Veroux, MD Giuseppe D’Arrigo, MD Alessia Giaquinta, MD Carla Virgilio, MD Alessandro Cappellani, MD Massimiliano Veroux, MD, PhD Department of Surgery, Transplantation and Advanced Technologies (P.V., A.G., C.V., A.C., M.V.) Vascular Surgery and Organ Transplant Unit University Hospital of Catania Via S. Sofia 86 Catania, IT 95123, Italy; and Unit of Cardiovascular Surgery (G.D.) Cannizzaro Emergency Hospital Catania, Italy
Editor: Pseudoaneurysm of the ascending aorta is an unusual and potentially life-threatening complication that occurs after cardiac surgical procedures. Surgical repair implies resternotomy, cardiopulmonary bypass, and moderate hypothermic circulatory arrest. These procedures are associated with significant morbidity and mortality (1). Endovascular treatment is very challenging because of the short landing zone, the disturbance of aortic valve function, and the risk of obturating the coronary and/or brachiocephalic arteries (2). Here we report an emergency endovascular exclusion of ascending aorta pseudoaneurysms in a patient unsuitable for open repair. A 76-year-old woman was admitted to the emergency room for bleeding of the sternum. Nine months earlier, she
None of the authors have identified a conflict of interest. DOI: 10.1016/j.jvir.2010.11.005
417
had undergone an elective bioprosthetic aortic and mitral valve replacement. A thoracic computed tomography (CT) scan showed two large pseudoaneurysms of the midportion of the ascending aorta (Figure, a). The patient’s advanced age and the need for a resternotomy, cardiopulmonary bypass, and moderate hypothermic circulatory arrest contraindicated open repair, so the patient was considered for endovascular exclusion. On CT, the distance between the aortic bioprosthetic valve and the first pseudoaneurysm was 18 mm (proximal neck); the distance between the right coronary ostium and the brachiocephalic trunk was 64 mm. An endovenous bolus of 5,000 IU heparin was administered before the procedure. A pacemaker catheter was introduced through the left femoral vein and positioned in the right ventricle. Surgical exposure of the left subclavian artery was obtained, and two additional 5-F sheaths were introduced into the right brachial artery and right femoral artery. A pigtail marker catheter was advanced from the femoral artery into the ascending aorta to measure the distance between the right coronary artery and the brachiocephalic trunk. A guide wire was advanced from the right brachial artery into the thoracic aorta to protect the brachiocephalic trunk. A guide wire was advanced into the ascending aorta from the left subclavian artery, positioned in the left ventricle, and exchanged for an extra-stiff Lunderquist guide wire (Cook, Bloomington, Indiana). After angiographic assessment, a 32 ⫻ 45-mm Endurant aortic cuff (Medtronic, Santa Rosa, California) was advanced over the stiff wire and deployed at the desired position. To ensure the best accuracy in endograft positioning, the stent-graft was deployed under rapid heart pacing at 180 beats/min to allow an arterial pressure of 40 mm Hg and was gently postdilated. Angiography confirmed total exclusion of the two pseudoaneurysms with antegrade flow into the coronary arteries and the brachiocephalic trunk. A transesophageal ultrasound study showed correct functioning of the aortic valve. The postoperative course was uneventful and the patient was discharged on the seventh postoperative day. A CT scan performed 90 days after the procedure confirmed the complete exclusion of both pseudoaneurysms (Figure, b). Postoperative pseudoaneurysm of the ascending aorta represents a rare (⬍ 1%) complication of cardiac surgery (1). Most cases occur at the level of the aortotomy (aortic valve replacement), the proximal anastomosis (coronary bypass), or at cannulation sites (1). Surgical treatment of pseudoaneurysm of the ascending aorta is challenging and may be associated with significant morbidity and mortality (1). The endovascular approach, in well-selected anatomic cases, may provide a life-saving and unique treatment opportunity for patients not suitable for open repair. A landing zone of at least 20 mm from the aortic valve cusps to the pseudoaneurysm is mandatory to obtain good proximal
ties of the visceral parent arteries. The only means to preserve the patency of the parent artery in these cases is to perform superselective arterial embolization by three-dimensional coil packing of the PA sac with use of controlled detachable microcoils placed in a concentric fashion, possibly in combination with an injection of Onyx embolic agent. We recently reported excellent results with this technique regardless of the clinical presentation, cause, or location of the lesion at the level of major peripheral or visceral arterial branches (4). We suggest that this conservative therapeutic option may deserve to be used whenever possible, as it preserves the patency of the parent artery. In conclusion, our experience suggests that transcatheter embolization with NBCA in well trained hands is effective and safe in patients with distal PAs, and does not cause more ischemic complications than other embolic agents if used cautiously. Conversely, glue embolization should absolutely not be attempted for PAs located at the level of major peripheral or visceral arteries.
REFERENCES 1. Song HH, Won YD, Kim YJ. Transcatheter N-butyl cyanoacrylate embolization of pseudoaneurysms. J Vasc Interv Radiol 2010; 21:1508 –1511. 2. Loffroy R, Guiu B, Cercueil JP, et al. Transcatheter arterial embolization of splenic artery aneurysms and pseudoaneurysms: short- and long-term results. Ann Vasc Surg 2008; 22:618 – 626. 3. Tokuda T, Tanigawa N, Shomura Y, et al. Transcatheter embolization for peripheral pseudoaneurysms with n-butyl cyanoacrylate. Minim Invasive Ther Allied Technol 2009; 18:361–365. 4. Loffroy R, Rao P, Ota S, et al. Packing technique for endovascular coil embolisation of peripheral arterial pseudo-aneurysms with preservation of the parent artery: safety, efficacy and outcomes. Eur J Vasc Endovasc Surg 2010; 40:209 –215.
Endovascular Stent-graft Placement for Retrograde Type A Aortic Dissection From: Jianjun Jiang, MD Xiangjiu Ding, MD Guangyong Zhang, MD Sanyuan Hu, MD Qingbo Su, MD Feng Li, MD Department of Vascular Surgery Qilu Hospital Shandong University 107 Wenhua Xi Road Jinan, 250012, P. R. China
Editor: Stanford type A aortic dissection is a life-threatening disease with a 50% risk of death within the first 48 hours. Descending thoracic aortic dissection extending into the ascending aorta is a special subgroup of type A dissection,
None of the authors have identified a conflict of interest. DOI: 10.1016/j.jvir.2010.11.019
415
which usually requires extensive aortic replacement. The surgical outcomes have improved with the development of surgical techniques and anesthesia, but the operative mortality rate is still high. Recently, combined surgical and endovascular treatment has been used for retrograde type A aortic dissection. Herein, we present a total endovascular stent-graft repair for type A aortic dissection with an entry tear in the descending aorta. We believe this to be a promising alternative to surgical graft replacement. A 57-year-old man with a history of hypertension presented with severe chest and abdominal pain. Blood pressure at admission was 190/110 mm Hg. The patient’s pain was refractory to pethidine hydrochloride. Computed tomographic (CT) angiography revealed a type A aortic dissection with an entry tear in the descending aorta. The descending aortic dissection retrogradely extended into the ascending aorta (Figure, a). The distance between the tear and the left subclavian artery was 10 mm. The diameter of the true lumen immediately proximal to the tear was 26 mm. Another entry tear was identified in the abdominal aorta and extended into the right iliac artery (Figure, b). The patient refused surgical graft replacement. Endovascular treatment was considered and informed consent was signed. Emergency endovascular repair was performed under general anesthesia. A left femoral arteriotomy was performed after intravenous administration of heparin (100 U/kg). Aortography confirmed the CT angiography findings. Cerebral angiography displayed that bilateral carotid arteries, vertebral artery, and circle of Willis were unobstructed. The left common carotid artery and the left subclavian artery were marked on the screen. A 32 ⫻ 150 mm Talent covered stent (Medtronic, Minneapolis, Minnesota) was selected. The diagnostic catheter was exchanged for the delivery system over a super-stiff guide wire (Lunderquist Extra Stiff; Cook, Bloomington, Indiana). When the top end of the endograft reached the left common carotid artery, the stent-graft was deployed by pulling back the sheath. Subsequent aortography showed the tear and the left subclavian artery were completely covered (Figure, c). No endoleak was observed. The arteriotomy site was sutured after sheath removal. The patient recovered successfully without limb ischemia. The abdominal aortic entry tear, untreated at the time of thoracic endograft placement, remained at 3-month follow-up; the patient was asymptomatic. CT revealed patency of the stent-graft with no endoleak. The thrombosed false lumen in the ascending aorta had obviously shrunk, and the true lumen had enlarged (Figure, d). More and more patients with type A dissection are managed by endovascular stent-graft repair (1–3), but there are still several issues to consider. There is still a controversy concerning the proper treatment. The standard approach for type A dissection is ascending aortic replacement, but many distal complications cannot be treated simultaneously. Although extended aortic replacement can
416 䡲 Letters to the Editor
Jiang et al 䡲 JVIR
Figure. (a) Preoperative CT scan with multiplanar reconstruction. The false lumen is thrombosed in the ascending and proximal descending aorta (stars). (b) Intraoperative angiogram shows the abdominal aorta separated into two lumens. The false lumen is patent (star). (c) Intraoperative aortogram after stent-graft placement reveals the orifice of the left subclavian artery is covered. The left common carotid artery (arrow) is patent. (d) CT image with maximum-intensity projection at 3-month follow-up shows that the true lumen in the ascending aorta has enlarged and the false lumen has shrunk.
manage the ascending and descending aortic pathologic processes together, the operative mortality rate is still high. Von Segesser proposed it should be managed in accordance with the site of the predominant lesion (4). In 2003, Jazayeri combined interventional graft placement and surgical repair to treat retrograde type A dissection (5). We agree with the viewpoint of Von Segesser and performed endovascular repair in our patient. The main objective of endovascular repair is not to eliminate the blood flow in the false lumen, but to seal the tears, restore the blood flow in the true lumen, relieve distal malperfusion, and prevent aortic rupture. Several cases of successful endovascular stent-graft repair of retrograde type A dissection have been reported (2,3,6). Endovascular stent-graft repair for acute aortic dissection is debated because the aortic wall is usually thin and
fragile (3). In the majority of reported cases (including the current case), repair was performed in the acute stage. In the reviewed reports, no significant complications have been reported. To obtain an adequate seal, the left subclavian artery is often covered with or without revascularization. Previous reports suggest that coverage of the left subclavian artery is generally safe and well tolerated (7). In the current case, the left vertebral artery was dominant, but the left subclavian artery was covered uneventfully without reconstruction. In conclusion, endovascular stent-graft repair was clinically successful, without complications, in this case. The safety and effectiveness as well as the longer-term results of this technique need to be confirmed by further studies.
Volume 22 䡲 Number 3 䡲 March 䡲 2011
REFERENCES 1. Park KB, Do YS, Kim SS, Kim DK, Choe YH. Endovascular treatment of acute complicated aortic dissection: long-term follow-up of clinical outcomes and CT findings. J Vasc Interv Radiol 2009; 20:334 –341. 2. Shimono T, Kato N, Tokui T, et al. Endovascular stent-graft repair for acute type a aortic dissection with an intimal tear in the descending aorta. J Thorac Cardiovasc Surg 1998; 116:171–173. 3. Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 1999; 340:1546 –1552. 4. von Segesser LK, Killer I, Ziswiler M, et al. Dissection of the descending thoracic aorta extending into the ascending aorta. A therapeutic challenge. J thorac Cardiovasc Surg 1994; 108:755–761. 5. Jazayeri S, Tatou E, Gomez MC, et al. Combined treatment of aortic type A dissection: ascending aorta repair and placement of a stent in the descending aorta. Heart Surg Forum 2003; 6:387–389. 6. Kato N, Shimono T, Hirano T, Ishida M, Yada I, Takeda K. Transluminal placement of endovascular stent-grafts for the treatment of type A aortic dissection with an entry tear in the descending thoracic aorta. J Vasc Surg 2001; 34:1023–1028. 7. Noor N, Sadat U, Hayes PD, Thompson MM, Boyle JR. Management of the left subclavian artery during endovascular repair of the thoracic aorta. J Endovasc Ther 2008; 15:168 –176.
Emergency Endovascular Repair of Two Ascending Aortic Pseudoaneurysms From: Pierfrancesco Veroux, MD Giuseppe D’Arrigo, MD Alessia Giaquinta, MD Carla Virgilio, MD Alessandro Cappellani, MD Massimiliano Veroux, MD, PhD Department of Surgery, Transplantation and Advanced Technologies (P.V., A.G., C.V., A.C., M.V.) Vascular Surgery and Organ Transplant Unit University Hospital of Catania Via S. Sofia 86 Catania, IT 95123, Italy; and Unit of Cardiovascular Surgery (G.D.) Cannizzaro Emergency Hospital Catania, Italy
Editor: Pseudoaneurysm of the ascending aorta is an unusual and potentially life-threatening complication that occurs after cardiac surgical procedures. Surgical repair implies resternotomy, cardiopulmonary bypass, and moderate hypothermic circulatory arrest. These procedures are associated with significant morbidity and mortality (1). Endovascular treatment is very challenging because of the short landing zone, the disturbance of aortic valve function, and the risk of obturating the coronary and/or brachiocephalic arteries (2). Here we report an emergency endovascular exclusion of ascending aorta pseudoaneurysms in a patient unsuitable for open repair. A 76-year-old woman was admitted to the emergency room for bleeding of the sternum. Nine months earlier, she
None of the authors have identified a conflict of interest. DOI: 10.1016/j.jvir.2010.11.005
417
had undergone an elective bioprosthetic aortic and mitral valve replacement. A thoracic computed tomography (CT) scan showed two large pseudoaneurysms of the midportion of the ascending aorta (Figure, a). The patient’s advanced age and the need for a resternotomy, cardiopulmonary bypass, and moderate hypothermic circulatory arrest contraindicated open repair, so the patient was considered for endovascular exclusion. On CT, the distance between the aortic bioprosthetic valve and the first pseudoaneurysm was 18 mm (proximal neck); the distance between the right coronary ostium and the brachiocephalic trunk was 64 mm. An endovenous bolus of 5,000 IU heparin was administered before the procedure. A pacemaker catheter was introduced through the left femoral vein and positioned in the right ventricle. Surgical exposure of the left subclavian artery was obtained, and two additional 5-F sheaths were introduced into the right brachial artery and right femoral artery. A pigtail marker catheter was advanced from the femoral artery into the ascending aorta to measure the distance between the right coronary artery and the brachiocephalic trunk. A guide wire was advanced from the right brachial artery into the thoracic aorta to protect the brachiocephalic trunk. A guide wire was advanced into the ascending aorta from the left subclavian artery, positioned in the left ventricle, and exchanged for an extra-stiff Lunderquist guide wire (Cook, Bloomington, Indiana). After angiographic assessment, a 32 ⫻ 45-mm Endurant aortic cuff (Medtronic, Santa Rosa, California) was advanced over the stiff wire and deployed at the desired position. To ensure the best accuracy in endograft positioning, the stent-graft was deployed under rapid heart pacing at 180 beats/min to allow an arterial pressure of 40 mm Hg and was gently postdilated. Angiography confirmed total exclusion of the two pseudoaneurysms with antegrade flow into the coronary arteries and the brachiocephalic trunk. A transesophageal ultrasound study showed correct functioning of the aortic valve. The postoperative course was uneventful and the patient was discharged on the seventh postoperative day. A CT scan performed 90 days after the procedure confirmed the complete exclusion of both pseudoaneurysms (Figure, b). Postoperative pseudoaneurysm of the ascending aorta represents a rare (⬍ 1%) complication of cardiac surgery (1). Most cases occur at the level of the aortotomy (aortic valve replacement), the proximal anastomosis (coronary bypass), or at cannulation sites (1). Surgical treatment of pseudoaneurysm of the ascending aorta is challenging and may be associated with significant morbidity and mortality (1). The endovascular approach, in well-selected anatomic cases, may provide a life-saving and unique treatment opportunity for patients not suitable for open repair. A landing zone of at least 20 mm from the aortic valve cusps to the pseudoaneurysm is mandatory to obtain good proximal