- Email: [email protected]
Reverse Frozen Elephant Trunk Procedure for Rescue of a Thoracic Stent-Graft in the False Lumen
Ann Thorac Surg 2015;99:1445–7
Reverse Frozen Elephant Trunk Procedure for Rescue of a Thoracic Stent-Graft in the False Lumen Monica A. Isabella, MD, and Eric E. Roselli, MD Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
Thoracic endovascular aortic repair (TEVAR) is now a common treatment for patients with descending aortic disease, including aortic dissection. As the indications for TEVAR have expanded, so has the complexity of complications. Retrograde aortic dissection may occur in 1% to 2% of patients after TEVAR. We present a patient who initially underwent TEVAR for a degenerative aneurysm followed by a proximal stent-graft extension for retrograde dissection that failed because of malposition within the false lumen. We performed a hybrid reverse frozen elephant trunk (RFET) operation as a salvage procedure for these complications. (Ann Thorac Surg 2015;99:1445–7) Ó 2015 by The Society of Thoracic Surgeons
C
A 56-year-old man presented with back pain and signs of malperfusion with claudication and bilateral leg numbness. He had a history of hypertension, diabetes, peripheral artery disease, chronic renal insufficiency, and chronic obstructive pulmonary disease. He underwent TEVAR for a degenerative descending aortic aneurysm 2 years earlier but later experienced growth of the proximal descending aorta with a focal retrograde dissection. He then underwent a left subclavian–to-carotid transposition and proximal stent-graft extension 5 months before presentation. A new computed tomographic scan confirmed the suspicion that the stent-graft extension was inadvertently placed in the false lumen of the aortic arch. The aortogram from his previous repair was obtained and showed Accepted for publication June 17, 2014. Presented at the Surgical Motion Picture Session of the Sixtieth Annual Meeting of the Southern Thoracic Surgical Association, Scottsdale, AZ, Oct 30–Nov 2, 2013. Address correspondence to Dr Roselli, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1445
the stiff wire outside the true lumen. However, it was unclear how his lower body was being perfused. Further review showed a tenuous situation, with the patient’s lower body being perfused by a type 3 endoleak (Figs 1A, 2). A rescue plan was devised with an RFET procedure (Video 1). Percutaneous wire access was obtained from the left femoral artery into the original stent-graft in the true lumen and into the stent-graft extension in the false lumen of the aortic arch. The patient was then cannulated through a side graft on the right axillary artery and a 16F extracorporeal membrane oxygenation cannula in the left common femoral artery. After median sternotomy, he was placed on full cardiopulmonary bypass and cooled to 18 C. The ascending aorta was cross-clamped, the supraaortic vessels dissected out, and the aorta transected at the sinotubular junction. After adequate cooling, the left common carotid and innominate arteries were clamped, and selective antegrade brain perfusion was established through the right axillary artery (flow rate, 10 mL/kg/min). The cross-clamp was removed and the supraaortic vessels transected at their origins. The arch was transected and the dissection flap was resected in the arch to reveal the previously placed catheter within the stent-graft extension in the false lumen. A new stent-graft (40 162 mm Valiant; Medtronic, Minneapolis, MN) was delivered and deployed in an antegrade fashion over the through-and-through wire. This provided coverage of the endoleak as well as extension of the proximal aortic repair to the level of the left common carotid artery. This step converted the proximal closed false lumen into a true lumen for continuity with the distal stent-grafts. A 40-mm Coda balloon catheter (Cook Inc, Bloomington, IN) placed into the new stent-graft served as a distal clamp. Perfusion to the lower body was then established through the femoral cannula. The supraaortic vessels were individually sewn to a 12 10-mm multibranched graft (Terumo, Ann Arbor, MI) in an end-to-end fashion with their native stumps oversewn. All anastomoses used a bovine pericardium strip for reinforcement. A 30-mm surgical graft was sewn to the proximal end of the new stent-graft and included the patient’s native aortic wall in the anastomosis. The branched graft was sewn end-to-side to the new aortic arch graft, and the graft was clamped more proximally. Full flow was reinstituted and rewarming begun. Finally, the sinotubular junction was recreated with an end-to-end anastomosis to the proximal surgical graft. An aortogram performed while rewarming took place showed underexpansion of the new stent-graft. Balloon dilation was performed through a 16F sheath
The Video can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2014. 06.097] on http://www.annalsthoracicsurgery.org. Dr Roselli discloses financial relationships with Medtronic, Cook Medical, and Terumo.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.05.101
FEATURE ARTICLES
omplications arising from thoracic endovascular aortic repair (TEVAR) are becoming more common as the indications for stent-grafting expand for patients with aortic aneurysms and dissections. Potentially fatal complications include retrograde aortic dissection and malpositioning in the false lumen. We report a hybrid salvage technique, the reverse frozen elephant trunk (RFET) procedure, for a patient who underwent TEVAR for a degenerative aneurysm complicated by a retrograde aortic dissection treated with a proximal stent-graft extension that was malpositioned in the false lumen.
CASE REPORT ISABELLA AND ROSELLI EMERGENT ENDOVASCULAR TREATMENT AFTER TEVAR
1446
CASE REPORT ISABELLA AND ROSELLI EMERGENT ENDOVASCULAR TREATMENT AFTER TEVAR
Ann Thorac Surg 2015;99:1445–7
FEATURE ARTICLES
Fig 1. (A) Preoperative volume-rendered reconstruction computed tomographic scan (TeraRecon, San Mateo, CA) revealed the false lumen blind pouch extending into the aortic arch (red arrow) with blood flow in the true lumen outside the stent-graft extension in the dissected aorta (blue arrow.) (B) Postoperative computed tomographic scan revealing an excellent thoracic repair 6 months later.
exchanged over the extracorporeal membrane oxygenation cannula. Before weaning the patient from cardiopulmonary bypass, completion aortography revealed a well-secured stent-graft with an excellent proximal repair and continuity of flow in the true lumen without endoleak. The patient had an unremarkable postoperative course. He was discharged to a skilled nursing facility on postoperative day 9. At the 6-month visit, he was doing well and his computed tomographic scan revealed an excellent thoracic repair with no endoleak and a decrease in the size of the residual aneurysmal sac (Fig 1B).
Comment With promising early results, not only has stent-grafting been used for degenerative aneurysms but its application has been extended to dissections, traumatic ruptures, intramural hematomas, penetrating ulcers, pseudoaneurysms, coarctations, and Kommerell’s diverticula [1]. Compared with open operations in a meta-analysis, TEVAR had a decreased risk of several common major complications [2]. Proximal aortic complications unique to TEVAR Fig 2. (A) Previous repair angiogram showed the stiff wire outside the true lumen (arrow). (B) Type 3 endoleak perfusing patient’s lower body (arrow).
include type 1 endoleaks, device migration, retrograde dissection, and rarely malpositioning in the false lumen [3–6]. These complications are often repaired with a hybrid technique [4, 7]. In this case, we demonstrated that the unusual complication of device misplacement into the false lumen of an aortic dissection can also be salvaged with a modified FET procedure [5, 6]. Unique to our patient was the retrograde dissection after his initial TEVAR followed by a malpositioned stent-graft and its long-term tolerance because of the type 3 endoleak. Closer inspection of the previous fluoroscopic images showing the guidewire separate from the column of contrast during angiography suggests that this complication could have been detected sooner. Using intravascular ultrasonography is important during stent-grafting for patients with aortic dissection because multiple communications between true and false lumens often exist. A low mortality rate of 5% from our institution after 19 RFET cases (9 urgent) demonstrates that with careful imaging-based planning, a safe rescue operation is feasible [8]. Proximal aortic complications can be expected to rise as TEVAR becomes more commonly applied in complex
Ann Thorac Surg 2015;99:1447–9
patients. Developing a clear reconstruction strategy is essential. In this patient, considerations included delivering an additional stent-graft to address both the type 3 endoleak and to move the anastomosis site proximally to facilitate hemostasis. Even the most serious proximal TEVAR complications can be safely managed with a wellplanned hybrid operation based on an understanding of the anatomy, pathologic features, and device construct, as well as a focused analysis of the preoperative imaging.
References
Thoracic Endovascular Aortic Repair After Iatrogenic Aortic Dissection and False Lumen Stent Grafting Claudia Schrimpf, MD, Omke E. Teebken, MD, and Mathias Wilhelmi, MD Division of Vascular- and Endovascular Surgery, Department of Cardiothoracic-, Transplantation-, and Vascular Surgery, Hannover Medical School, Hannover, Germany
Iatrogenic aortic dissections are a severe complication after thoracic endovascular aortic repair, and treatment guidelines do not exist. Herein, we report a patient who experienced an iatrogenic type B aortic dissection during elective thoracic endovascular aortic repair and suggest an interventional treatment option. (Ann Thorac Surg 2015;99:1447–9) Ó 2015 by The Society of Thoracic Surgeons Accepted for publication May 28, 2014. Address correspondence to Dr Schrimpf, Hannover Medical School, Department of Cardiothoracic-, Transplantation-, and Vascular Surgery, Division of Vascular- and Endovascular Surgery, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1447
T
horacic endovascular aortic repair (TEVAR) is a common treatment for aneurysms in the descending aorta that is carried out in primary care hospitals throughout Germany. A severe complication of TEVAR is the occurrence of an iatrogenic aortic dissection. The cause of the dissection is often unknown; nevertheless, it is likely that the dissection may need immediate treatment. The following case report broaches the issue of an iatrogenic aortic dissection during TEVAR, and not only provides a treatment option but also discusses possible periprocedural steps during which the dissection might have happened. A 68-year-old male patient with an asymptomatic descending aortic aneurysm (62 mm diameter) presented in another hospital for elective TEVAR (Fig 1A). Concomitant diseases comprised hypertension, chronic obstructive pulmonary disease (GOLD III-IV), nicotine abuse, and asymptomatic peripheral arterial disease. After gaining access over the right calcified femoral artery, 5,000 U of heparin was given. A sheath was introduced, and an angiography of the thoracoabdominal aorta was performed. A wire was introduced, and a new angiography to determine the distal landing zone was performed. Afterwards, a larger sheath (24F Gore DrySeal, W.L. Gore & Assoc, Flagstaff, AZ) was inserted. Because of difficulties advancing the sheath, an angioplasty of the iliac vessels was performed twice before the sheath was introduced into the aorta. Wires were switched to an extra-stiff guidewire, and a stent graft (Gore cTAG, diameter 40 mm) was inserted and unleashed, followed by balloon remodeling. The completion angiogram showed a newly developed aortic type B dissection with subtotal occlusion of the aorta starting at the left subclavian artery and ending at the proximal rim of the graft. Emergency therapy consisted of a balloon angioplasty using a left brachial approach, with the intention to push the stent graft and the dissection membrane to the vascular wall, but the attempt failed. The intervention was discontinued, and after closing the access site, the patient was delivered to the ward. The patient had reduced groin pulses and exhibited paresthesia of both legs. A computed tomography scan was performed after the patient experienced paraplegia and abdominal pain. It showed a partial occlusion of the thoracic aorta as well as graft misplacement within the aortic wall (Fig 1B). The patient was immediately transferred to our center. An initial blood draw revealed creatine kinase, 109 U/L; creatinine, 108 mmol/L; aspartate aminotransferase, 29U/L; alanine aminotransferase, 24 U/L; myoglobin, 336 mg/L; and lactate within normal range. We decided on an endovascular approach to reestablish the aortic lumen. In case the interventional approach should fail, the patient was brought to a fully equipped cardiothoracic operating room with heart-and-lung machine and x-ray imaging. Overall time between aortic occlusion and initiation of the emergency procedure was 5 hours. After an unsuccessful attempt to pass the stent graft through the femoral artery, an antegrade access through the right brachial artery was performed. The misplaced endograft was passed, and the wire (Glidewire Advantage 0.03500 ; Terumo, Somerset, NJ) was retrieved in the right common femoral artery. Using this wire as a guiding 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.05.101
FEATURE ARTICLES
1. Brozzi NA, Roselli EE. Endovascular therapy for thoracic aortic aneurysms: state of the art in 2012. Curr Treat Options Cardiovasc Med 2012;14:149–63. 2. Cheng D, Martin J, Shennib H, et al. Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease: a systematic review and meta-analysis of comparative studies. J Am Coll Cardiol 2010;55:986–1001. 3. Williams JB, Anderson ND, Bhattacharva SD, et al. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg 2012;55:1255–62. 4. Idrees J, Arafat A, Johnston DR, Svensson LG, Roselli EE. Repair of retrograde ascending dissection after descending stent grafting. J Thorac Cardiovasc Surg 2014;147:151–4. 5. Follis F, Filippone G, Stabile A, et al. Endovascular graft deployment in the false lumen of type B dissection. Interact Cardiovasc Thorac Surg 2010;10:597–9. 6. Zhang R, Kofidis T, Baus S, Klima U. Iatrogenic type A dissection after attempted stenting of a descending aortic aneurysm. Ann Thorac Surg 2006;82:1523–5. 7. Roselli EE, Abdel-Halim M, Johnston D, et al. Open aortic repair following prior thoracic endovascular aortic repair. Ann Thorac Surg 2014;97:750–6. 8. Lima B, Roselli EE, Soltesz EG, et al. Modified and “reverse” frozen elephant trunk repairs for extensive disease and complications after stent grafting. Ann Thorac Surg 2012;93:103–9.
CASE REPORT SCHRIMPF ET AL EMERGENT ENDOVASCULAR TREATMENT AFTER TEVAR
Reverse Frozen Elephant Trunk Procedure for Rescue of a Thoracic Stent-Graft in the False Lumen Monica A. Isabella, MD, and Eric E. Roselli, MD Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
Thoracic endovascular aortic repair (TEVAR) is now a common treatment for patients with descending aortic disease, including aortic dissection. As the indications for TEVAR have expanded, so has the complexity of complications. Retrograde aortic dissection may occur in 1% to 2% of patients after TEVAR. We present a patient who initially underwent TEVAR for a degenerative aneurysm followed by a proximal stent-graft extension for retrograde dissection that failed because of malposition within the false lumen. We performed a hybrid reverse frozen elephant trunk (RFET) operation as a salvage procedure for these complications. (Ann Thorac Surg 2015;99:1445–7) Ó 2015 by The Society of Thoracic Surgeons
C
A 56-year-old man presented with back pain and signs of malperfusion with claudication and bilateral leg numbness. He had a history of hypertension, diabetes, peripheral artery disease, chronic renal insufficiency, and chronic obstructive pulmonary disease. He underwent TEVAR for a degenerative descending aortic aneurysm 2 years earlier but later experienced growth of the proximal descending aorta with a focal retrograde dissection. He then underwent a left subclavian–to-carotid transposition and proximal stent-graft extension 5 months before presentation. A new computed tomographic scan confirmed the suspicion that the stent-graft extension was inadvertently placed in the false lumen of the aortic arch. The aortogram from his previous repair was obtained and showed Accepted for publication June 17, 2014. Presented at the Surgical Motion Picture Session of the Sixtieth Annual Meeting of the Southern Thoracic Surgical Association, Scottsdale, AZ, Oct 30–Nov 2, 2013. Address correspondence to Dr Roselli, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1445
the stiff wire outside the true lumen. However, it was unclear how his lower body was being perfused. Further review showed a tenuous situation, with the patient’s lower body being perfused by a type 3 endoleak (Figs 1A, 2). A rescue plan was devised with an RFET procedure (Video 1). Percutaneous wire access was obtained from the left femoral artery into the original stent-graft in the true lumen and into the stent-graft extension in the false lumen of the aortic arch. The patient was then cannulated through a side graft on the right axillary artery and a 16F extracorporeal membrane oxygenation cannula in the left common femoral artery. After median sternotomy, he was placed on full cardiopulmonary bypass and cooled to 18 C. The ascending aorta was cross-clamped, the supraaortic vessels dissected out, and the aorta transected at the sinotubular junction. After adequate cooling, the left common carotid and innominate arteries were clamped, and selective antegrade brain perfusion was established through the right axillary artery (flow rate, 10 mL/kg/min). The cross-clamp was removed and the supraaortic vessels transected at their origins. The arch was transected and the dissection flap was resected in the arch to reveal the previously placed catheter within the stent-graft extension in the false lumen. A new stent-graft (40 162 mm Valiant; Medtronic, Minneapolis, MN) was delivered and deployed in an antegrade fashion over the through-and-through wire. This provided coverage of the endoleak as well as extension of the proximal aortic repair to the level of the left common carotid artery. This step converted the proximal closed false lumen into a true lumen for continuity with the distal stent-grafts. A 40-mm Coda balloon catheter (Cook Inc, Bloomington, IN) placed into the new stent-graft served as a distal clamp. Perfusion to the lower body was then established through the femoral cannula. The supraaortic vessels were individually sewn to a 12 10-mm multibranched graft (Terumo, Ann Arbor, MI) in an end-to-end fashion with their native stumps oversewn. All anastomoses used a bovine pericardium strip for reinforcement. A 30-mm surgical graft was sewn to the proximal end of the new stent-graft and included the patient’s native aortic wall in the anastomosis. The branched graft was sewn end-to-side to the new aortic arch graft, and the graft was clamped more proximally. Full flow was reinstituted and rewarming begun. Finally, the sinotubular junction was recreated with an end-to-end anastomosis to the proximal surgical graft. An aortogram performed while rewarming took place showed underexpansion of the new stent-graft. Balloon dilation was performed through a 16F sheath
The Video can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2014. 06.097] on http://www.annalsthoracicsurgery.org. Dr Roselli discloses financial relationships with Medtronic, Cook Medical, and Terumo.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.05.101
FEATURE ARTICLES
omplications arising from thoracic endovascular aortic repair (TEVAR) are becoming more common as the indications for stent-grafting expand for patients with aortic aneurysms and dissections. Potentially fatal complications include retrograde aortic dissection and malpositioning in the false lumen. We report a hybrid salvage technique, the reverse frozen elephant trunk (RFET) procedure, for a patient who underwent TEVAR for a degenerative aneurysm complicated by a retrograde aortic dissection treated with a proximal stent-graft extension that was malpositioned in the false lumen.
CASE REPORT ISABELLA AND ROSELLI EMERGENT ENDOVASCULAR TREATMENT AFTER TEVAR
1446
CASE REPORT ISABELLA AND ROSELLI EMERGENT ENDOVASCULAR TREATMENT AFTER TEVAR
Ann Thorac Surg 2015;99:1445–7
FEATURE ARTICLES
Fig 1. (A) Preoperative volume-rendered reconstruction computed tomographic scan (TeraRecon, San Mateo, CA) revealed the false lumen blind pouch extending into the aortic arch (red arrow) with blood flow in the true lumen outside the stent-graft extension in the dissected aorta (blue arrow.) (B) Postoperative computed tomographic scan revealing an excellent thoracic repair 6 months later.
exchanged over the extracorporeal membrane oxygenation cannula. Before weaning the patient from cardiopulmonary bypass, completion aortography revealed a well-secured stent-graft with an excellent proximal repair and continuity of flow in the true lumen without endoleak. The patient had an unremarkable postoperative course. He was discharged to a skilled nursing facility on postoperative day 9. At the 6-month visit, he was doing well and his computed tomographic scan revealed an excellent thoracic repair with no endoleak and a decrease in the size of the residual aneurysmal sac (Fig 1B).
Comment With promising early results, not only has stent-grafting been used for degenerative aneurysms but its application has been extended to dissections, traumatic ruptures, intramural hematomas, penetrating ulcers, pseudoaneurysms, coarctations, and Kommerell’s diverticula [1]. Compared with open operations in a meta-analysis, TEVAR had a decreased risk of several common major complications [2]. Proximal aortic complications unique to TEVAR Fig 2. (A) Previous repair angiogram showed the stiff wire outside the true lumen (arrow). (B) Type 3 endoleak perfusing patient’s lower body (arrow).
include type 1 endoleaks, device migration, retrograde dissection, and rarely malpositioning in the false lumen [3–6]. These complications are often repaired with a hybrid technique [4, 7]. In this case, we demonstrated that the unusual complication of device misplacement into the false lumen of an aortic dissection can also be salvaged with a modified FET procedure [5, 6]. Unique to our patient was the retrograde dissection after his initial TEVAR followed by a malpositioned stent-graft and its long-term tolerance because of the type 3 endoleak. Closer inspection of the previous fluoroscopic images showing the guidewire separate from the column of contrast during angiography suggests that this complication could have been detected sooner. Using intravascular ultrasonography is important during stent-grafting for patients with aortic dissection because multiple communications between true and false lumens often exist. A low mortality rate of 5% from our institution after 19 RFET cases (9 urgent) demonstrates that with careful imaging-based planning, a safe rescue operation is feasible [8]. Proximal aortic complications can be expected to rise as TEVAR becomes more commonly applied in complex
Ann Thorac Surg 2015;99:1447–9
patients. Developing a clear reconstruction strategy is essential. In this patient, considerations included delivering an additional stent-graft to address both the type 3 endoleak and to move the anastomosis site proximally to facilitate hemostasis. Even the most serious proximal TEVAR complications can be safely managed with a wellplanned hybrid operation based on an understanding of the anatomy, pathologic features, and device construct, as well as a focused analysis of the preoperative imaging.
References
Thoracic Endovascular Aortic Repair After Iatrogenic Aortic Dissection and False Lumen Stent Grafting Claudia Schrimpf, MD, Omke E. Teebken, MD, and Mathias Wilhelmi, MD Division of Vascular- and Endovascular Surgery, Department of Cardiothoracic-, Transplantation-, and Vascular Surgery, Hannover Medical School, Hannover, Germany
Iatrogenic aortic dissections are a severe complication after thoracic endovascular aortic repair, and treatment guidelines do not exist. Herein, we report a patient who experienced an iatrogenic type B aortic dissection during elective thoracic endovascular aortic repair and suggest an interventional treatment option. (Ann Thorac Surg 2015;99:1447–9) Ó 2015 by The Society of Thoracic Surgeons Accepted for publication May 28, 2014. Address correspondence to Dr Schrimpf, Hannover Medical School, Department of Cardiothoracic-, Transplantation-, and Vascular Surgery, Division of Vascular- and Endovascular Surgery, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1447
T
horacic endovascular aortic repair (TEVAR) is a common treatment for aneurysms in the descending aorta that is carried out in primary care hospitals throughout Germany. A severe complication of TEVAR is the occurrence of an iatrogenic aortic dissection. The cause of the dissection is often unknown; nevertheless, it is likely that the dissection may need immediate treatment. The following case report broaches the issue of an iatrogenic aortic dissection during TEVAR, and not only provides a treatment option but also discusses possible periprocedural steps during which the dissection might have happened. A 68-year-old male patient with an asymptomatic descending aortic aneurysm (62 mm diameter) presented in another hospital for elective TEVAR (Fig 1A). Concomitant diseases comprised hypertension, chronic obstructive pulmonary disease (GOLD III-IV), nicotine abuse, and asymptomatic peripheral arterial disease. After gaining access over the right calcified femoral artery, 5,000 U of heparin was given. A sheath was introduced, and an angiography of the thoracoabdominal aorta was performed. A wire was introduced, and a new angiography to determine the distal landing zone was performed. Afterwards, a larger sheath (24F Gore DrySeal, W.L. Gore & Assoc, Flagstaff, AZ) was inserted. Because of difficulties advancing the sheath, an angioplasty of the iliac vessels was performed twice before the sheath was introduced into the aorta. Wires were switched to an extra-stiff guidewire, and a stent graft (Gore cTAG, diameter 40 mm) was inserted and unleashed, followed by balloon remodeling. The completion angiogram showed a newly developed aortic type B dissection with subtotal occlusion of the aorta starting at the left subclavian artery and ending at the proximal rim of the graft. Emergency therapy consisted of a balloon angioplasty using a left brachial approach, with the intention to push the stent graft and the dissection membrane to the vascular wall, but the attempt failed. The intervention was discontinued, and after closing the access site, the patient was delivered to the ward. The patient had reduced groin pulses and exhibited paresthesia of both legs. A computed tomography scan was performed after the patient experienced paraplegia and abdominal pain. It showed a partial occlusion of the thoracic aorta as well as graft misplacement within the aortic wall (Fig 1B). The patient was immediately transferred to our center. An initial blood draw revealed creatine kinase, 109 U/L; creatinine, 108 mmol/L; aspartate aminotransferase, 29U/L; alanine aminotransferase, 24 U/L; myoglobin, 336 mg/L; and lactate within normal range. We decided on an endovascular approach to reestablish the aortic lumen. In case the interventional approach should fail, the patient was brought to a fully equipped cardiothoracic operating room with heart-and-lung machine and x-ray imaging. Overall time between aortic occlusion and initiation of the emergency procedure was 5 hours. After an unsuccessful attempt to pass the stent graft through the femoral artery, an antegrade access through the right brachial artery was performed. The misplaced endograft was passed, and the wire (Glidewire Advantage 0.03500 ; Terumo, Somerset, NJ) was retrieved in the right common femoral artery. Using this wire as a guiding 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.05.101
FEATURE ARTICLES
1. Brozzi NA, Roselli EE. Endovascular therapy for thoracic aortic aneurysms: state of the art in 2012. Curr Treat Options Cardiovasc Med 2012;14:149–63. 2. Cheng D, Martin J, Shennib H, et al. Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease: a systematic review and meta-analysis of comparative studies. J Am Coll Cardiol 2010;55:986–1001. 3. Williams JB, Anderson ND, Bhattacharva SD, et al. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg 2012;55:1255–62. 4. Idrees J, Arafat A, Johnston DR, Svensson LG, Roselli EE. Repair of retrograde ascending dissection after descending stent grafting. J Thorac Cardiovasc Surg 2014;147:151–4. 5. Follis F, Filippone G, Stabile A, et al. Endovascular graft deployment in the false lumen of type B dissection. Interact Cardiovasc Thorac Surg 2010;10:597–9. 6. Zhang R, Kofidis T, Baus S, Klima U. Iatrogenic type A dissection after attempted stenting of a descending aortic aneurysm. Ann Thorac Surg 2006;82:1523–5. 7. Roselli EE, Abdel-Halim M, Johnston D, et al. Open aortic repair following prior thoracic endovascular aortic repair. Ann Thorac Surg 2014;97:750–6. 8. Lima B, Roselli EE, Soltesz EG, et al. Modified and “reverse” frozen elephant trunk repairs for extensive disease and complications after stent grafting. Ann Thorac Surg 2012;93:103–9.
CASE REPORT SCHRIMPF ET AL EMERGENT ENDOVASCULAR TREATMENT AFTER TEVAR