- Email: [email protected]
Primary Endovascular Treatment of Native Thoracic Aortic Aneurysm Associated with Coarctation
EJVES Extra 14, 36e38 (2007) doi:10.1016/j.ejvsextra.2007.05.004, available online at http://www.sciencedirect.com on
SHORT REPORT
Primary Endovascular Treatment of Native Thoracic Aortic Aneurysm Associated with Coarctation H. Karabulut,1 S. Senay,1* F. Toraman,1 H. Cagil2 and C. Alhan1 2
Departments of 1Cardiovascular Surgery, and Radiology, Acibadem Kadikoy Hospital, Istanbul, Turkey
We report a successful endovascular stenting of a native thoracic aortic aneurysm associated with coarctation of a 47 year old female patient who did not have previous surgery. Main problems regarding to the endovascular treatment of this pathology and possible solutions are discussed. Ó 2007 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. Keywords: Aortic coarctation; Aneurysm; Endovascular.
Introduction Coarctation of the aorta accounts for 3% to 5% of all congenital cardiac malformations.1 Endovascular treatment techniques for primary or recurrent concomitant aneurysms after a surgical repair is well documented.1e5 The recurrent aneurysm formation after surgical repair is most commonly associated with synthetic patch-plasty, it typically occurs opposite to the synthetic patch at the proximal descending aorta.4 However the characteristics of primary aneurysms may differ from recurrent aneurysms in means of the site of the diseased segment and maturity of the neighboring distal vascular branches. We report a successful endovascular stenting of a coarctationassociated native thoracic aortic aneurysm.
Report A 47-year-old female presented with uncontrolled hypertension (with 240e250 mmHg systolic pressure), dyspnea and a systolic murmur. Computed *Corresponding author. S. Senay, Acibadem Kadikoy Hospital, Department of Cardiovascular Surgery, Ozlem Sitesi B Blok D, 25 Kosuyolu- Uskudar, 81100 Istanbul, Turkey. E-mail address: [email protected]
tomographic scan and aortography showed aortic coarctation located 15 mm distally from the origin of the left subclavian artery and an aneurysm of 5 cm in length and 4 cm in diameter originating from the coarcted segment with a gradient of 60 mmHg (Fig. 1a, b). Coarctation and aneurysm were treated using direct placement of a Valiant thoracic stent graft (22F REF: TF2424C100X) and subsequent balloon dilatation through the abdominal and thoracic aorta via the right femoral artery. The completion angiography revealed excellent patency with no endoleak and the left subclavian artery was perfused normally (Fig. 1c). The patient was transferred to the intensive care unit with stabile hemodynamic parameters. On the 1st postoperative day the patient underwent left brachial thrombectomy due to acute thrombosis of the brachial artery. No other complication occurred. The patient was discharged on day 5. Control CT after 5 months showed a patent stent with no evidence of endoleak (Fig. 2).
Discussion Late aneurysm formation of untreated subclinical coarctation as well as aneurysm formation after coarctation repair is associated with a high incidence of fatal rupture.1e4 Endovascular treatment appears to
1533–3167/000036 + 03 $32.00/0 Ó 2007 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Endovascular Treatment of Aneurysmatic Coarctation
37
Fig. 1. a, b: Arteriograms showing an aortic coarctation with an associated aneurysm. c: Stent graft and balloon dilation was applied. No endoleak is determined.
be a safe alternative to open surgery.1 Recurrent aneurysms after coarctation repair are usually localized at the proximal descending aorta and can usually be treated with straightforward transfemoral endovascular techniques. However native aortic aneurysms associated with untreated coarctation can be found
Fig. 2. Control computed tomographic image at the 5th month. The left subclavian artery is regularly perfused. No endoleak is determined.
in the descending aorta or extending more proximal into the aortic arch.1,2,5 Thus, inadequate landing zones and a considerable risk of obstruction of the supraaortic branches can be encountered. A branched aortic graft may be required for these aneurysms. Deployment of the endovascular stent may not be possible through femoral or the iliac arteries due to severe stenosis or occlusion of the aorta, or severe tortuosity of the iliac arteries or the abdominal. Antegrade endoluminal stent graft deployment through a minimally invasive sternal sparing incision has been reported as an alternative method for this situation.5 There is a substantial risk of rupture during the procedure. On the other hand, endoleaks or stent-graft occlusion may be encountered due to insufficient radial force of the graft against the aortic wall. So the choice of graft is important. The length of the graft is important for the development of paraplegia, and it should be kept as small as to cover the pathology with a distal sealing zone of grater than 15 mm. The aneurysm was located at the descending aorta and the distal vascular structures were adequate for an endovascular procedure in our case, thus we were able to perform the deployment of the catheter and the endovascular stent through the femoral arteries. However, the pathology in native aneurysm with coarctation can also be more complex as described before. So the treatment may require hybrid approaches or alternative access sites. As a conclusion, aortic aneurysm formation of both coarctation repair and untreated subclinical coarctation can be treated with endovascular techniques. The procedure may require alternative access sites EJVES Extra Vol 14, September 2007
38
H. Karabulut et al.
or additional debranching of supraaortic vessels due to the complexity of the pathology in native aneurysms of untreated coarctation.
References 1 BELL RE, TAYLOR PR, AUKETT M, YOUNG CP, ANDERSON DR, REIDY JF. Endoluminal repair of aneurysms associated with coarctation. Ann Thorac Surg 2003;75:530e533. 2 JOHN A, GUNN J, BOWES RJ, GAINES PA, HAMM CW. Interventional therapy of aortic isthmus stenosis with concomitant thoracic aortic aneurysm with a stent graft. Zeitschrift fur Kardiologie 2000;89: 962e964.
EJVES Extra Vol 14, September 2007
3 HARRISON DA, MCLAUGHLIN PR, LAZZAM C, CONNELLY M, BENSON LN. Endovascular stents in the management of coarctation of the aorta in the adolescent and adult: one year follow up. Heart 2001;85:561e566. 4 PARKS WJ, NGO TD, PLAUTH Jr WH, BANK ER, SHEPPARD SK, PETTIGREW RI et al. Incidence of aneurysm formation after Dacron patch angioplasty repair for coarctation of the aorta: long term results and assessment utilizing magnetic resonance angiography with three dimensional surface rendering. J Am Coll Cardiol 1995;26:266e271. 5 DEROSE JJ, MARTIN EC, ASHTON RC, BELSLEY S, SWISTEL DG, TODD GJ. Antegrade endovascular repair of a coarctation-associated aneurysm through an upper hemi-sternotomy. Ann Thorac Surg 2004; 78:28e29. Accepted 31 May 2007
SHORT REPORT
Primary Endovascular Treatment of Native Thoracic Aortic Aneurysm Associated with Coarctation H. Karabulut,1 S. Senay,1* F. Toraman,1 H. Cagil2 and C. Alhan1 2
Departments of 1Cardiovascular Surgery, and Radiology, Acibadem Kadikoy Hospital, Istanbul, Turkey
We report a successful endovascular stenting of a native thoracic aortic aneurysm associated with coarctation of a 47 year old female patient who did not have previous surgery. Main problems regarding to the endovascular treatment of this pathology and possible solutions are discussed. Ó 2007 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. Keywords: Aortic coarctation; Aneurysm; Endovascular.
Introduction Coarctation of the aorta accounts for 3% to 5% of all congenital cardiac malformations.1 Endovascular treatment techniques for primary or recurrent concomitant aneurysms after a surgical repair is well documented.1e5 The recurrent aneurysm formation after surgical repair is most commonly associated with synthetic patch-plasty, it typically occurs opposite to the synthetic patch at the proximal descending aorta.4 However the characteristics of primary aneurysms may differ from recurrent aneurysms in means of the site of the diseased segment and maturity of the neighboring distal vascular branches. We report a successful endovascular stenting of a coarctationassociated native thoracic aortic aneurysm.
Report A 47-year-old female presented with uncontrolled hypertension (with 240e250 mmHg systolic pressure), dyspnea and a systolic murmur. Computed *Corresponding author. S. Senay, Acibadem Kadikoy Hospital, Department of Cardiovascular Surgery, Ozlem Sitesi B Blok D, 25 Kosuyolu- Uskudar, 81100 Istanbul, Turkey. E-mail address: [email protected]
tomographic scan and aortography showed aortic coarctation located 15 mm distally from the origin of the left subclavian artery and an aneurysm of 5 cm in length and 4 cm in diameter originating from the coarcted segment with a gradient of 60 mmHg (Fig. 1a, b). Coarctation and aneurysm were treated using direct placement of a Valiant thoracic stent graft (22F REF: TF2424C100X) and subsequent balloon dilatation through the abdominal and thoracic aorta via the right femoral artery. The completion angiography revealed excellent patency with no endoleak and the left subclavian artery was perfused normally (Fig. 1c). The patient was transferred to the intensive care unit with stabile hemodynamic parameters. On the 1st postoperative day the patient underwent left brachial thrombectomy due to acute thrombosis of the brachial artery. No other complication occurred. The patient was discharged on day 5. Control CT after 5 months showed a patent stent with no evidence of endoleak (Fig. 2).
Discussion Late aneurysm formation of untreated subclinical coarctation as well as aneurysm formation after coarctation repair is associated with a high incidence of fatal rupture.1e4 Endovascular treatment appears to
1533–3167/000036 + 03 $32.00/0 Ó 2007 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Endovascular Treatment of Aneurysmatic Coarctation
37
Fig. 1. a, b: Arteriograms showing an aortic coarctation with an associated aneurysm. c: Stent graft and balloon dilation was applied. No endoleak is determined.
be a safe alternative to open surgery.1 Recurrent aneurysms after coarctation repair are usually localized at the proximal descending aorta and can usually be treated with straightforward transfemoral endovascular techniques. However native aortic aneurysms associated with untreated coarctation can be found
Fig. 2. Control computed tomographic image at the 5th month. The left subclavian artery is regularly perfused. No endoleak is determined.
in the descending aorta or extending more proximal into the aortic arch.1,2,5 Thus, inadequate landing zones and a considerable risk of obstruction of the supraaortic branches can be encountered. A branched aortic graft may be required for these aneurysms. Deployment of the endovascular stent may not be possible through femoral or the iliac arteries due to severe stenosis or occlusion of the aorta, or severe tortuosity of the iliac arteries or the abdominal. Antegrade endoluminal stent graft deployment through a minimally invasive sternal sparing incision has been reported as an alternative method for this situation.5 There is a substantial risk of rupture during the procedure. On the other hand, endoleaks or stent-graft occlusion may be encountered due to insufficient radial force of the graft against the aortic wall. So the choice of graft is important. The length of the graft is important for the development of paraplegia, and it should be kept as small as to cover the pathology with a distal sealing zone of grater than 15 mm. The aneurysm was located at the descending aorta and the distal vascular structures were adequate for an endovascular procedure in our case, thus we were able to perform the deployment of the catheter and the endovascular stent through the femoral arteries. However, the pathology in native aneurysm with coarctation can also be more complex as described before. So the treatment may require hybrid approaches or alternative access sites. As a conclusion, aortic aneurysm formation of both coarctation repair and untreated subclinical coarctation can be treated with endovascular techniques. The procedure may require alternative access sites EJVES Extra Vol 14, September 2007
38
H. Karabulut et al.
or additional debranching of supraaortic vessels due to the complexity of the pathology in native aneurysms of untreated coarctation.
References 1 BELL RE, TAYLOR PR, AUKETT M, YOUNG CP, ANDERSON DR, REIDY JF. Endoluminal repair of aneurysms associated with coarctation. Ann Thorac Surg 2003;75:530e533. 2 JOHN A, GUNN J, BOWES RJ, GAINES PA, HAMM CW. Interventional therapy of aortic isthmus stenosis with concomitant thoracic aortic aneurysm with a stent graft. Zeitschrift fur Kardiologie 2000;89: 962e964.
EJVES Extra Vol 14, September 2007
3 HARRISON DA, MCLAUGHLIN PR, LAZZAM C, CONNELLY M, BENSON LN. Endovascular stents in the management of coarctation of the aorta in the adolescent and adult: one year follow up. Heart 2001;85:561e566. 4 PARKS WJ, NGO TD, PLAUTH Jr WH, BANK ER, SHEPPARD SK, PETTIGREW RI et al. Incidence of aneurysm formation after Dacron patch angioplasty repair for coarctation of the aorta: long term results and assessment utilizing magnetic resonance angiography with three dimensional surface rendering. J Am Coll Cardiol 1995;26:266e271. 5 DEROSE JJ, MARTIN EC, ASHTON RC, BELSLEY S, SWISTEL DG, TODD GJ. Antegrade endovascular repair of a coarctation-associated aneurysm through an upper hemi-sternotomy. Ann Thorac Surg 2004; 78:28e29. Accepted 31 May 2007