- Email: [email protected]
Surgical Treatment of Acute Thoracic Stent Graft Occlusion
Accepted Manuscript Surgical Treatment of Acute Thoracic Stent-Graft Occlusion Omayra C.D. Liesdek, MD, Kirolos A. Jacob, MD PhD, Aryan Vink, MD PhD, Marijn A. Vermeulen, MD, Constantijn E.V.B. Hazenberg, MD PhD, Willem J.L. Suyker, MD PhD PII:
S0003-4975(18)30992-5
DOI:
10.1016/j.athoracsur.2018.05.099
Reference:
ATS 31765
To appear in:
The Annals of Thoracic Surgery
Received Date: 11 March 2018 Revised Date:
28 May 2018
Accepted Date: 31 May 2018
Please cite this article as: Liesdek OCD, Jacob KA, Vink A, Vermeulen MA, Hazenberg CEVB, Suyker WJL, Surgical Treatment of Acute Thoracic Stent-Graft Occlusion, The Annals of Thoracic Surgery (2018), doi: 10.1016/j.athoracsur.2018.05.099. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Surgical Treatment of Acute Thoracic Stent-Graft Occlusion
Omayra C.D. Liesdek MD1, Kirolos A. Jacob MD PhD1, Aryan Vink MD PhD2, Marijn A.
RI PT
Vermeulen MD2, Constantijn E.V.B. Hazenberg MD PhD3, Willem J.L. Suyker MD PhD1
Departments of Cardiothoracic Surgery1, Pathology2 and Vascular Surgery3, University
M AN U
SC
Medical Center Utrecht, Utrecht University, The Netherlands.
Corresponding Author:
TE D
Word Count: 1500
EP
Omayra C.D. Liesdek, MD; University Medical Center Utrecht, Department of Cardiothoracic Surgery. Room number E03.511, PO Box 85500, 3508 GA Utrecht, The Netherlands. Email:
AC C
[email protected]
1
ACCEPTED MANUSCRIPT Abstract An adolescent male presented with acute onset paraplegia related to complete occlusion of a thoracic stent-graft placed 2 years earlier for repair of traumatic type B aortic dissection. Following emergency surgery comprising reestablishment of aortic flow by stent removal and
RI PT
aortic reconstruction, the paraplegia started to resolve partly, despite an estimated 5 hours interval of preoperative myelum ischemia. Anatomical characteristics of the stent-graft placement appear to have played a role in causing this rare complication. Six months later, the patient could walk again with a stick. This case shows that early intervention in case of
AC C
EP
TE D
M AN U
SC
full paraplegia may be considered.
2
ACCEPTED MANUSCRIPT During the past 15 years, open surgical repair for traumatic thoracic aortic injury (TTAI) has increasingly been replaced by thoracic endovascular aortic repair (TEVAR).1 Serious complications, however, may still occur and can be a challenge to deal with. Here we report a rare case of stent-graft occlusion after TEVAR in a young trauma patient, resulting in acute
RI PT
paraplegia that turned out to be at least partially reversible after prompt surgical intervention.
A 24 year old man with a history of an acute TEVAR (VAMF2424C122 ValiantTM CaptiviaTM traumatic type B thoracic aortic dissection
SC
Medtronic Company; United States) for a
(DeBakey Type III) after a motorcycle accident two years ago, was referred to the emergency
M AN U
room because of acute complete motoric and sensory loss of both lower limbs while jogging. Nausea and vomiting suggested abdominal ischemia as well.
Contrast Computer Tomography scanning of the thorax and abdomen demonstrated a total occlusion of the thoracic aortic stent-graft (Figure 1), with no evidence of thrombo-
TE D
embolization or ischemic injury to the abdominal organs. The acute onset of paraplegia was related to total occlusion of the thoracic aortic stent-graft resulting in ischemia of the spinal myelum.
EP
Emergency surgery followed in order to reestablish aortic flow. Access was gained via left lateral thoracotomy. To prevent further deterioration of the clinical status of the
AC C
myelum, quick reperfusion of the lower body and deep cooling was instituted through double arterial cannulation, i.e. in the ascending aortic and the left femoral artery respectively. Venous cannulation of the left femoral vein followed. Deep hypothermia (20 degrees Celsius) was achieved with subsequent circulatory arrest. The occluded stent-graft was explanted, along with the aortic wall it was attached to. A tubular prosthetic graft (24 mm GelweaveTM; Vascutek ltd, Terumo Company, United Kingdom), with a length of approximately 15 cm, was then sutured to connect the proximal and distal descending aorta. Total circulatory arrest time was 27 minutes, aortic cross clamping time was 127 minutes and total cardiopulmonary bypass duration was 222 minutes. 3
ACCEPTED MANUSCRIPT Macroscopic and histological examination of the explanted stent graft showed detachment of the neointima that had been formed inside the stent from the stent wall (Figure 2). The neointima was partly attached to the proximal stent struts and showed a total of 4 defects connecting the lumen and the area between the neointima and the stent wall. In
RI PT
the distal part of the stent, complete circular detachment of the neointima from the stent wall was observed with a mix of recent and older organized hematoma between the neointima and the stent wall.
Neurological examination showed some recovery on the first day after surgery; the
SC
paraplegia had slightly improved. Eleven days after surgery, at the time of discharge to a rehabilitation center, the patient was able to actively move his legs against gravity, sensibility
M AN U
in both legs was completely restored and voluntary control over micturition and defecation was present. Six months after the surgery, the patient was able to walk with a stick.
Comment
TE D
Stent-graft occlusion after TEVAR is a rare complication. Prompt treatment of this catastrophic event is crucial in order to resolve organ and tissue malperfusion. Initially, we considered thrombolysis. For two reasons, however, we chose surgical intervention. First, a
EP
large thrombus like this was not expected to evenly dissolve but rather to disintegrate, causing massive embolization and considerable ischemic organ and tissue damage. Second,
AC C
in order to maximize the chance of some spinal cord recovery, prompt surgical reperfusion was preferred. An extra-anatomic solution like an axillo-femoral bypass was considered suboptimal given the patients young age and otherwise good health. Instead, we preferred anatomical repair and rapid reperfusion using cardiopulmonary bypass and double arterial cannulation in the upper and lower body . Anatomic- and/or graft-related factors may have contributed to stent-graft occlusion. The characteristics of currently used stent-grafts for the management of TTAI are not specifically designed for traumatic patients, and usually have their indication in patients with degenerative aortic disease. These stents may have difficulty accommodating delivery in a 4
ACCEPTED MANUSCRIPT small-diameter aorta with a tightly curved aortic arch and relatively high pulsatile compliance and flow velocity. Therefore, radial oversizing is often necessitated. As in our case, in acute setting of the TEVAR an on-the-shelf thoracic stent-graft was used. Despite only little oversizing, proximal sealing was sufficient at the level of the left subclavian artery. The
RI PT
relatively high pulsatile pressure and flow velocity in the aorta, however, may have induced a recurring force across the implanted stent-graft that may have caused intima detachment and subsequent progressive thrombus formation.
In addition, the relatively stiff stent-graft with a landing zone in the tight and steep
SC
aortic arch may have resulted in the bird-beak phenomenon (Figure 3), which is a known risk factor for device collapse. Stent collapse occurs predominantly after graft oversizing in
M AN U
combination with a tight aortic arch.2 In case of bird-beaking, the stent-graft protrudes into the aortic lumen. This situation may significantly alter the hemodynamic and structural loads exerted on the neointima within the stent-graft, thus causing extensive shear stress.3 As such, this phenomenon could also have caused detachment of the neointima in the case of
TE D
our patient.
Histopathological examination of the explanted stent-graft revealed a neointima consisting of connective tissue with myofibroblasts that was detached from the wall of the
EP
stent with a hematoma between the stent and the neointima. When the amount of connective tissue in an intimal lesion increases, the lesion may show shrinkage, just like a scar in the
AC C
skin. For atherosclerotic and restenosis lesions this phenomenon of constrictive remodeling has been extensively studied.4 Due to a layer of Teflon inside the stent-graft, the neointima cannot strongly connect to the stent-graft. This might lead to a less stable connection between neointima and the surrounding structures. Taking this into consideration, natural shrinkage of the neointimal layer might as well have played a role in causing detachment from the stent. We have discussed multiple options for stent-graft occlusion which may alone, or in combination, explain this unfortunate complication. Paraplegia tremendously deteriorates the
5
ACCEPTED MANUSCRIPT quality of life of patients if it persists. Therefore, we considered a prompt and maximally invasive treatment to restore antegrade perfusion into the descending aorta. In conclusion, we present a rare case of total occlusion of a stent-graft after TEVAR leading to paraplegia due to myelum ischemia. Fast surgical intervention in order to
RI PT
reestablish blood circulation of the lower body was successful with a relatively favorable
AC C
EP
TE D
M AN U
SC
neurologic outcome.
6
ACCEPTED MANUSCRIPT
References 1. Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic
RI PT
injury: clinical practice guidelines of the society for vascular surgery. J Vasc Surg 2011; 53: 187–192.
2. Tadros RO, Lipsitz EC, Chaer RA, et al. A multicenter experience of the management of collapsed thoracic endografts. J Vasc Surg 2011; 53: 1217–1222.
SC
3. Rinaudo A, Raffa GM, Scardulla F, et al. Biomechanical implications of excessive
2015; 66: 235-241.
M AN U
endograft protrusion into the aortic arch after thoracic endovascular repair. Comput Biol Med
4. Pasterkamp G, de Kleijn DP, Borst C. Arterial remodeling in atherosclerosis, restenosis and after alteration of blood flow: potential mechanisms and clinical implications. Cardiovasc
AC C
EP
TE D
Res. 2000 Mar;45(4):843-852.
7
ACCEPTED MANUSCRIPT
Figure Legends Figure 1. Computed Tomography (CT) demonstrating occlusion of the thoracic stent-graft
RI PT
(red arrows) on sagittal CT (A) and coronal CT (B) images.
Figure 2. Examination of explanted stent-graft. (A) Explanted stent-graft. Prox: proximal part; dist: distal part.
(B) Distal part of the stent with complete circular detachment of the
SC
neointima from the stent wall and a hematoma between the neointima and the stent wall. (C) Histopathological examination, using hematoxylin and eosin stain, of the neointima with a
M AN U
recent (<1 day old) and an organized (at least one week old) hematoma around the neointima; l: lumen; ni: neointima; bl: blood; oh: organized hematoma; bar = 5mm.
Figure 3. Sagittal Computed Tomography demonstrating bird-beak configuration (red arrow).
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EP
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Stent-graft protrusion into the lumen of the aortic arch.
8
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
S0003-4975(18)30992-5
DOI:
10.1016/j.athoracsur.2018.05.099
Reference:
ATS 31765
To appear in:
The Annals of Thoracic Surgery
Received Date: 11 March 2018 Revised Date:
28 May 2018
Accepted Date: 31 May 2018
Please cite this article as: Liesdek OCD, Jacob KA, Vink A, Vermeulen MA, Hazenberg CEVB, Suyker WJL, Surgical Treatment of Acute Thoracic Stent-Graft Occlusion, The Annals of Thoracic Surgery (2018), doi: 10.1016/j.athoracsur.2018.05.099. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Surgical Treatment of Acute Thoracic Stent-Graft Occlusion
Omayra C.D. Liesdek MD1, Kirolos A. Jacob MD PhD1, Aryan Vink MD PhD2, Marijn A.
RI PT
Vermeulen MD2, Constantijn E.V.B. Hazenberg MD PhD3, Willem J.L. Suyker MD PhD1
Departments of Cardiothoracic Surgery1, Pathology2 and Vascular Surgery3, University
M AN U
SC
Medical Center Utrecht, Utrecht University, The Netherlands.
Corresponding Author:
TE D
Word Count: 1500
EP
Omayra C.D. Liesdek, MD; University Medical Center Utrecht, Department of Cardiothoracic Surgery. Room number E03.511, PO Box 85500, 3508 GA Utrecht, The Netherlands. Email:
AC C
[email protected]
1
ACCEPTED MANUSCRIPT Abstract An adolescent male presented with acute onset paraplegia related to complete occlusion of a thoracic stent-graft placed 2 years earlier for repair of traumatic type B aortic dissection. Following emergency surgery comprising reestablishment of aortic flow by stent removal and
RI PT
aortic reconstruction, the paraplegia started to resolve partly, despite an estimated 5 hours interval of preoperative myelum ischemia. Anatomical characteristics of the stent-graft placement appear to have played a role in causing this rare complication. Six months later, the patient could walk again with a stick. This case shows that early intervention in case of
AC C
EP
TE D
M AN U
SC
full paraplegia may be considered.
2
ACCEPTED MANUSCRIPT During the past 15 years, open surgical repair for traumatic thoracic aortic injury (TTAI) has increasingly been replaced by thoracic endovascular aortic repair (TEVAR).1 Serious complications, however, may still occur and can be a challenge to deal with. Here we report a rare case of stent-graft occlusion after TEVAR in a young trauma patient, resulting in acute
RI PT
paraplegia that turned out to be at least partially reversible after prompt surgical intervention.
A 24 year old man with a history of an acute TEVAR (VAMF2424C122 ValiantTM CaptiviaTM traumatic type B thoracic aortic dissection
SC
Medtronic Company; United States) for a
(DeBakey Type III) after a motorcycle accident two years ago, was referred to the emergency
M AN U
room because of acute complete motoric and sensory loss of both lower limbs while jogging. Nausea and vomiting suggested abdominal ischemia as well.
Contrast Computer Tomography scanning of the thorax and abdomen demonstrated a total occlusion of the thoracic aortic stent-graft (Figure 1), with no evidence of thrombo-
TE D
embolization or ischemic injury to the abdominal organs. The acute onset of paraplegia was related to total occlusion of the thoracic aortic stent-graft resulting in ischemia of the spinal myelum.
EP
Emergency surgery followed in order to reestablish aortic flow. Access was gained via left lateral thoracotomy. To prevent further deterioration of the clinical status of the
AC C
myelum, quick reperfusion of the lower body and deep cooling was instituted through double arterial cannulation, i.e. in the ascending aortic and the left femoral artery respectively. Venous cannulation of the left femoral vein followed. Deep hypothermia (20 degrees Celsius) was achieved with subsequent circulatory arrest. The occluded stent-graft was explanted, along with the aortic wall it was attached to. A tubular prosthetic graft (24 mm GelweaveTM; Vascutek ltd, Terumo Company, United Kingdom), with a length of approximately 15 cm, was then sutured to connect the proximal and distal descending aorta. Total circulatory arrest time was 27 minutes, aortic cross clamping time was 127 minutes and total cardiopulmonary bypass duration was 222 minutes. 3
ACCEPTED MANUSCRIPT Macroscopic and histological examination of the explanted stent graft showed detachment of the neointima that had been formed inside the stent from the stent wall (Figure 2). The neointima was partly attached to the proximal stent struts and showed a total of 4 defects connecting the lumen and the area between the neointima and the stent wall. In
RI PT
the distal part of the stent, complete circular detachment of the neointima from the stent wall was observed with a mix of recent and older organized hematoma between the neointima and the stent wall.
Neurological examination showed some recovery on the first day after surgery; the
SC
paraplegia had slightly improved. Eleven days after surgery, at the time of discharge to a rehabilitation center, the patient was able to actively move his legs against gravity, sensibility
M AN U
in both legs was completely restored and voluntary control over micturition and defecation was present. Six months after the surgery, the patient was able to walk with a stick.
Comment
TE D
Stent-graft occlusion after TEVAR is a rare complication. Prompt treatment of this catastrophic event is crucial in order to resolve organ and tissue malperfusion. Initially, we considered thrombolysis. For two reasons, however, we chose surgical intervention. First, a
EP
large thrombus like this was not expected to evenly dissolve but rather to disintegrate, causing massive embolization and considerable ischemic organ and tissue damage. Second,
AC C
in order to maximize the chance of some spinal cord recovery, prompt surgical reperfusion was preferred. An extra-anatomic solution like an axillo-femoral bypass was considered suboptimal given the patients young age and otherwise good health. Instead, we preferred anatomical repair and rapid reperfusion using cardiopulmonary bypass and double arterial cannulation in the upper and lower body . Anatomic- and/or graft-related factors may have contributed to stent-graft occlusion. The characteristics of currently used stent-grafts for the management of TTAI are not specifically designed for traumatic patients, and usually have their indication in patients with degenerative aortic disease. These stents may have difficulty accommodating delivery in a 4
ACCEPTED MANUSCRIPT small-diameter aorta with a tightly curved aortic arch and relatively high pulsatile compliance and flow velocity. Therefore, radial oversizing is often necessitated. As in our case, in acute setting of the TEVAR an on-the-shelf thoracic stent-graft was used. Despite only little oversizing, proximal sealing was sufficient at the level of the left subclavian artery. The
RI PT
relatively high pulsatile pressure and flow velocity in the aorta, however, may have induced a recurring force across the implanted stent-graft that may have caused intima detachment and subsequent progressive thrombus formation.
In addition, the relatively stiff stent-graft with a landing zone in the tight and steep
SC
aortic arch may have resulted in the bird-beak phenomenon (Figure 3), which is a known risk factor for device collapse. Stent collapse occurs predominantly after graft oversizing in
M AN U
combination with a tight aortic arch.2 In case of bird-beaking, the stent-graft protrudes into the aortic lumen. This situation may significantly alter the hemodynamic and structural loads exerted on the neointima within the stent-graft, thus causing extensive shear stress.3 As such, this phenomenon could also have caused detachment of the neointima in the case of
TE D
our patient.
Histopathological examination of the explanted stent-graft revealed a neointima consisting of connective tissue with myofibroblasts that was detached from the wall of the
EP
stent with a hematoma between the stent and the neointima. When the amount of connective tissue in an intimal lesion increases, the lesion may show shrinkage, just like a scar in the
AC C
skin. For atherosclerotic and restenosis lesions this phenomenon of constrictive remodeling has been extensively studied.4 Due to a layer of Teflon inside the stent-graft, the neointima cannot strongly connect to the stent-graft. This might lead to a less stable connection between neointima and the surrounding structures. Taking this into consideration, natural shrinkage of the neointimal layer might as well have played a role in causing detachment from the stent. We have discussed multiple options for stent-graft occlusion which may alone, or in combination, explain this unfortunate complication. Paraplegia tremendously deteriorates the
5
ACCEPTED MANUSCRIPT quality of life of patients if it persists. Therefore, we considered a prompt and maximally invasive treatment to restore antegrade perfusion into the descending aorta. In conclusion, we present a rare case of total occlusion of a stent-graft after TEVAR leading to paraplegia due to myelum ischemia. Fast surgical intervention in order to
RI PT
reestablish blood circulation of the lower body was successful with a relatively favorable
AC C
EP
TE D
M AN U
SC
neurologic outcome.
6
ACCEPTED MANUSCRIPT
References 1. Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic
RI PT
injury: clinical practice guidelines of the society for vascular surgery. J Vasc Surg 2011; 53: 187–192.
2. Tadros RO, Lipsitz EC, Chaer RA, et al. A multicenter experience of the management of collapsed thoracic endografts. J Vasc Surg 2011; 53: 1217–1222.
SC
3. Rinaudo A, Raffa GM, Scardulla F, et al. Biomechanical implications of excessive
2015; 66: 235-241.
M AN U
endograft protrusion into the aortic arch after thoracic endovascular repair. Comput Biol Med
4. Pasterkamp G, de Kleijn DP, Borst C. Arterial remodeling in atherosclerosis, restenosis and after alteration of blood flow: potential mechanisms and clinical implications. Cardiovasc
AC C
EP
TE D
Res. 2000 Mar;45(4):843-852.
7
ACCEPTED MANUSCRIPT
Figure Legends Figure 1. Computed Tomography (CT) demonstrating occlusion of the thoracic stent-graft
RI PT
(red arrows) on sagittal CT (A) and coronal CT (B) images.
Figure 2. Examination of explanted stent-graft. (A) Explanted stent-graft. Prox: proximal part; dist: distal part.
(B) Distal part of the stent with complete circular detachment of the
SC
neointima from the stent wall and a hematoma between the neointima and the stent wall. (C) Histopathological examination, using hematoxylin and eosin stain, of the neointima with a
M AN U
recent (<1 day old) and an organized (at least one week old) hematoma around the neointima; l: lumen; ni: neointima; bl: blood; oh: organized hematoma; bar = 5mm.
Figure 3. Sagittal Computed Tomography demonstrating bird-beak configuration (red arrow).
AC C
EP
TE D
Stent-graft protrusion into the lumen of the aortic arch.
8
AC C
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TE D
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SC
RI PT
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