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Thoracic aorta aneurysm repair using the right axillary approach
VASCULAR AND ENDOVASCULAR TECHNIQUES Thomas L. Forbes, MD, Section Editor
Thoracic aorta aneurysm repair using the right axillary approach Samuel S. Ahn, MD, Robert W. Feldtman, MD, and Foster A. Hays, BS, Dallas, Tex We present a 66-year-old man with a 5.7-cm saccular descending thoracic aortic aneurysm and a smaller 4.6-cm aneurysm just proximal to the celiac artery. The patient was judged to be too risky for open surgical repair because of poor anatomy and health. Previous stenting of the iliac arteries for a kinked aortoiliac open graft precluded conventional endovascular aneurysm repair. The descending thoracic aorta was successfully repaired using endovascular methods with a standard Talent (Medtronic, Los Angeles, Calif) thoracic proximal main stent graft, which was reverse-loaded onto the delivery device and delivered antegrade through the right axillary artery. ( J Vasc Surg 2011;54:1201-4.)
Endografts have rapidly become the standard treatment for thoracic aorta aneurysms. A variety of methods have been developed for both open and endovascular treatment. We present a patient with a unique anatomy and medical history that necessitated a novel approach of endovascular repair using a reverse-loaded endograft delivered through the right axillary artery. CASE REPORT A 66-year-old man presented with a 5.7-cm saccular descending thoracic aortic aneurysm and a smaller 4.6-cm aneurysm between the saccular aneurysm and the celiac artery. A descending thoracic aorta dissection was also found above the saccular aneurysm. The patient had undergone a previous emergency open aortobiiliac artery bypass graft for a ruptured abdominal aortic aneurysm, placement of a right common iliac stent for occlusive disease, and placement of stents in the renal, celiac, and superior mesenteric arteries. Vascular and endovascular technique. An initial endovascular repair attempt of the aorta through the right groin revealed that the external and common iliac arteries were extremely tortuous and diseased, including excessive graft limb tortuosity. Residual stenosis and kinking persisted despite multiple attempts of balloon angioplasty. We were not able to pass an endograft through the iliac lesions. A thoracic aortogram showed that the patient had a type I aortic arch, although the innominate, subclavian, and carotid From DFW Vascular Group. Competition of interest: none. Reprint requests: Dr Samuel S. Ahn, DFW Vascular Group, 221 W. Colorado Blvd, Ste 625, Dallas, TX 75208 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest. 0741-5214/$36.00 Copyright © 2011 by the Society for Vascular Surgery. doi:10.1016/j.jvs.2011.05.003
arteries were all extremely tortuous. Intravascular ultrasound imaging showed that the right axillary artery was widely patent, free of disease, and 8-mm in diameter. The right and left subclavian arteries and the left axillary arteries were also suitable alternative access sites to the thoracic aorta. We believed that an antegrade approach from the right axillary artery was the best option; however, we decided that an antegrade approach would require reversal of the endograft to avoid the bare metal encroaching on the pre-existing celiac, superior mesenteric artery, and renal artery stents that were protruding into the aorta. Procedure and device. After preparing and draping the patient for the procedure, but before making our incision, a standard 34 ⫻ 34 ⫻ 115-mm Talent Thoracic Proximal Main endograft using the Xcelerant Delivery System (Medtronic, Los Angeles, Calif) was deployed and removed on a sterile back table. The endograft was reversed, compressed by hand, and wrapped in umbilical tape to maintain compression. The endograft was reinserted into the sheath, and the umbilical tape was removed so that the endograft was now reverse-loaded in the delivery system (Fig 1). General endotracheal anesthesia was used for this procedure. The right axillary artery was exposed using a transverse infraclavicular incision. The patient was systemically heparinized. A longitudinal arteriotomy in the axillary artery allowed a 10-mm Hemashield (Boston Scientific, Natick, Mass) Dacron graft to be sutured end-to-side to the artery using 5-0 Prolene suture (Ethicon, Somerville, NJ). We opened the inflow and outflow to the axillary artery and then clamped the conduit. We punctured the conduit and catheterized the right axillary artery with an 8F introducer sheath. An angled glidewire (Terumo, Somerset, NJ) was passed through the axillary artery down through the descending thoracic aorta to the left branch of the aortobiiliac bypass graft. The glidewire was switched for a 260-cm Amplatz Super Stiff wire (Cook Medical, Bloomington, Ind). We passed an 8F intravascular ultrasound catheter (Boston Scientific) and interrogated the axillary, subcla-
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Fig 1. Illustrations show the progression of the reverse-loading procedure using umbilical tape to maintain compression of the Talent endograft. A, The proximal main endograft was deployed, reversed, and wrapped in umbilical tape to maintain compression. B, The endograft was reinserted into the sheath. C, The umbilical tape was removed so the endograft was reverse-loaded in the delivery system.
vian, and innominate arteries, which measured 10, 12, and 14 mm in diameter, respectively. The arteries were free of any stenotic lesions that would hinder endograft delivery. An angiogram confirmed the preoperative computed tomography diagnosis of a dissection of the thoracic aorta above the saccular aneurysm. Owing to the location of the two aneurysms, we determined that spinal cord protection was unnecessary for this procedure. The Super Stiff wire was swapped with a Lundquist wire (Cook Medical) for additional stiffness. We then delivered the Talent endograft over the Lundquist wire from the axillary artery. To ensure proper placement, angiograms were simultaneously performed during the delivery and deployment of the endograft, helped by a pigtail catheter placed in the transverse aortic arch from a right common femoral artery access. The endograft was placed so that it covered the dissection and the larger saccular aneurysm (Fig 2). The endograft was not postdilated due to the dissected thoracic aorta. A final angiogram confirmed no endoleak and full coverage of the saccular aneurysm and dissection. The endograft terminated distally with a 1-cm protrusion into the smaller aneurysm, which was not treated due to its relatively smaller size (Fig 3). The patient made a quick postoperative recovery and was discharged the next day with a small axillary hematoma, which resolved quickly. A computed tomography scan at 1 month showed no change in aneurysm size.
DISCUSSION Unfavorable iliac anatomy is a significant hindering factor for endovascular aneurysm repair (EVAR) of the aorta.1 Tortuous vessels, stenosis, or occlusion of the aortic bifurcation, the iliac arteries, or the small iliac vessels can make the retrograde approach for thoracic EVAR
(TEVAR) difficult to impossible. The European Collaborators on Stent-Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry reports that up to 13% of patients exhibit poor anatomic configuration or occlusive disease, which makes them poor candidates for EVAR.2 TEVARs using a carotid artery access have been reported by Heidenrich et al3 and Ghosh et al.4 The primary advantage for the left carotid approach is the favorable angle for wire delivery to the descending thoracic aorta, especially for type I aortic arches. There are also examples by Probst et al5 and Wudel et al6 of stent graft repair of thoracic artery aneurysms using the right axillary approach for endograft repair of the descending thoracic aorta. Ghosh et al4 also demonstrated the reverse loading technique for an aortouniiliac endograft that was custom designed for antegrade delivery. The main difference in this patient was that the stent graft was an unmodified device that was reverse-loaded into the Talent delivery system. Ghosh et al4 reported the reverse-loading technique for a custom device. The device used in this procedure was designed for retrograde delivery; however, preprocedure deployment and reverse-loading, as shown here, is an effective alternative to stent grafts designed for retrograde delivery. The carotid approach has a potential to impair blood flow to the brain. Heidenreich et al3 reported a stroke that resolved quickly within the postoperative period. This potential makes the axillary approach appear more favorable than the carotid approach. The risk of stroke for all TEVAR of descending thoracic aorta aneurysms is well documented.7 Roselli et al8 reported four patients with antegrade TEVAR of the ascending thoracic aorta; however,
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Fig 3. Illustration shows of the full deployment of the Talent endograft over the saccular aneurysm, terminating in the distal aneurysm with distal stents visible.
Fig 2. Illustration shows the deployment of the Talent endograft with distal stents visible.
their sample size was not quite adequate to demonstrate the safety and efficacy of the antegrade approach compared with the safety and efficacy of the retrograde approach. Wudel et al6 believed that a Dacron conduit access of the axillary artery was required due to the artery’s relatively small size. However, Probst et al5 concluded that the conduit might not be needed. The antegrade approach in our patient traversed through a type I aortic arch; however, going through a type II or type III aortic arch, although potentially more difficult, is not precluded by this approach. Probst et al,5 indeed, reports successful treatment in a patient with a type III aortic arch. Type II or III aortic arches make the carotid approach significantly more difficult and perhaps unsafe. Other arteries to consider include the left axillary, subclavian, or innominate arteries. It is
conceivable that a patient’s anatomy may allow for more favorable TEVAR through these arteries; however, antegrade TEVAR through these arteries has not been reported. We chose the Talent stent graft due to its length and geometry; however, we reasoned that its bare metal flared end in this patient’s smaller supraceliac aneurysm might possibly erode the aneurysm wall or impinge on the protruding pre-existing stents. Thus, we reversed the endograft to keep the bare metal proximal and the covered end of the endograft distal. The smaller aneurysm was not repaired because it was close to the previous renal and celiac artery stenting and was relatively small. CONCLUSIONS This case demonstrates the efficacy of the reverseloading technique for an unmodified stent graft using the right axillary artery approach. This technique opens up other possibilities for patients for whom endovascular repair would be preferred.
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The authors would like to acknowledge Julia F. Chen for providing all three illustrations. REFERENCES 1. Murray D, Ghosh J, Khwaja N, Murphy MO, Baguneid MS, Walker MG, et al. Access for endovascular aneurysm repair. J Endovasc Ther 2006; 13:754-61. 2. Cuypers PW, Laheij RJ, Buth J. Which factors increase the risk of conversion to pen surgery following endovascular abdominal aortic aneurysm repair? The EUROSTAR collaborators. Eur J Vasc Endovasc Surg 2000;20:183-9. 3. Heidenrich MJ, Neschis DG, Costanza MJ, Flinn WR. Endovascular repair of a penetrating thoracic aortic ulcer by way of the carotid artery. J Vasc Surg 2003;38:1407-10. 4. Ghosh J, Murray D, Farquharson F, Serracino-Inglott F. Abdominal aortic aneurysm repair: the carotid approach. J Vasc Surg 2009;49:763-6.
JOURNAL OF VASCULAR SURGERY October 2011
5. Probst C, Esmailzadeh B, Schiller W, Wilhelm K. Emergent antegrade endovascular stent placement in a patient with perforated Stanford B dissection via right axillary artery. Eur J Cadiothorac Surg 2008;33: 1148-9. 6. Wudel JH, Williams JB. Right axillary artery conduit for antegrade deployment of a thoracic aortic endoprosthesis. J Thorac Cadiovsc Surg 2008;135:436-7. 7. Gutsche JT, Cheung AT, McGarvey ML, Moser WG, Szeto W, Carpenter JP, et al. Risk factors for perioperative stroke after thoracic endovascular aortic repair. Ann Thorac Surg 2007;84:1195-200. 8. Roselli EE, Soltesz EG, Mastracci T, Svensson LG, Lytle BW. Antegrade delivery of stent grafts to treat complex thoracic aortic disease. Ann Thorac Surg 2010;90:539-46.
Submitted Aug 26, 2010; accepted May 5, 2011.
Thoracic aorta aneurysm repair using the right axillary approach Samuel S. Ahn, MD, Robert W. Feldtman, MD, and Foster A. Hays, BS, Dallas, Tex We present a 66-year-old man with a 5.7-cm saccular descending thoracic aortic aneurysm and a smaller 4.6-cm aneurysm just proximal to the celiac artery. The patient was judged to be too risky for open surgical repair because of poor anatomy and health. Previous stenting of the iliac arteries for a kinked aortoiliac open graft precluded conventional endovascular aneurysm repair. The descending thoracic aorta was successfully repaired using endovascular methods with a standard Talent (Medtronic, Los Angeles, Calif) thoracic proximal main stent graft, which was reverse-loaded onto the delivery device and delivered antegrade through the right axillary artery. ( J Vasc Surg 2011;54:1201-4.)
Endografts have rapidly become the standard treatment for thoracic aorta aneurysms. A variety of methods have been developed for both open and endovascular treatment. We present a patient with a unique anatomy and medical history that necessitated a novel approach of endovascular repair using a reverse-loaded endograft delivered through the right axillary artery. CASE REPORT A 66-year-old man presented with a 5.7-cm saccular descending thoracic aortic aneurysm and a smaller 4.6-cm aneurysm between the saccular aneurysm and the celiac artery. A descending thoracic aorta dissection was also found above the saccular aneurysm. The patient had undergone a previous emergency open aortobiiliac artery bypass graft for a ruptured abdominal aortic aneurysm, placement of a right common iliac stent for occlusive disease, and placement of stents in the renal, celiac, and superior mesenteric arteries. Vascular and endovascular technique. An initial endovascular repair attempt of the aorta through the right groin revealed that the external and common iliac arteries were extremely tortuous and diseased, including excessive graft limb tortuosity. Residual stenosis and kinking persisted despite multiple attempts of balloon angioplasty. We were not able to pass an endograft through the iliac lesions. A thoracic aortogram showed that the patient had a type I aortic arch, although the innominate, subclavian, and carotid From DFW Vascular Group. Competition of interest: none. Reprint requests: Dr Samuel S. Ahn, DFW Vascular Group, 221 W. Colorado Blvd, Ste 625, Dallas, TX 75208 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest. 0741-5214/$36.00 Copyright © 2011 by the Society for Vascular Surgery. doi:10.1016/j.jvs.2011.05.003
arteries were all extremely tortuous. Intravascular ultrasound imaging showed that the right axillary artery was widely patent, free of disease, and 8-mm in diameter. The right and left subclavian arteries and the left axillary arteries were also suitable alternative access sites to the thoracic aorta. We believed that an antegrade approach from the right axillary artery was the best option; however, we decided that an antegrade approach would require reversal of the endograft to avoid the bare metal encroaching on the pre-existing celiac, superior mesenteric artery, and renal artery stents that were protruding into the aorta. Procedure and device. After preparing and draping the patient for the procedure, but before making our incision, a standard 34 ⫻ 34 ⫻ 115-mm Talent Thoracic Proximal Main endograft using the Xcelerant Delivery System (Medtronic, Los Angeles, Calif) was deployed and removed on a sterile back table. The endograft was reversed, compressed by hand, and wrapped in umbilical tape to maintain compression. The endograft was reinserted into the sheath, and the umbilical tape was removed so that the endograft was now reverse-loaded in the delivery system (Fig 1). General endotracheal anesthesia was used for this procedure. The right axillary artery was exposed using a transverse infraclavicular incision. The patient was systemically heparinized. A longitudinal arteriotomy in the axillary artery allowed a 10-mm Hemashield (Boston Scientific, Natick, Mass) Dacron graft to be sutured end-to-side to the artery using 5-0 Prolene suture (Ethicon, Somerville, NJ). We opened the inflow and outflow to the axillary artery and then clamped the conduit. We punctured the conduit and catheterized the right axillary artery with an 8F introducer sheath. An angled glidewire (Terumo, Somerset, NJ) was passed through the axillary artery down through the descending thoracic aorta to the left branch of the aortobiiliac bypass graft. The glidewire was switched for a 260-cm Amplatz Super Stiff wire (Cook Medical, Bloomington, Ind). We passed an 8F intravascular ultrasound catheter (Boston Scientific) and interrogated the axillary, subcla-
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Fig 1. Illustrations show the progression of the reverse-loading procedure using umbilical tape to maintain compression of the Talent endograft. A, The proximal main endograft was deployed, reversed, and wrapped in umbilical tape to maintain compression. B, The endograft was reinserted into the sheath. C, The umbilical tape was removed so the endograft was reverse-loaded in the delivery system.
vian, and innominate arteries, which measured 10, 12, and 14 mm in diameter, respectively. The arteries were free of any stenotic lesions that would hinder endograft delivery. An angiogram confirmed the preoperative computed tomography diagnosis of a dissection of the thoracic aorta above the saccular aneurysm. Owing to the location of the two aneurysms, we determined that spinal cord protection was unnecessary for this procedure. The Super Stiff wire was swapped with a Lundquist wire (Cook Medical) for additional stiffness. We then delivered the Talent endograft over the Lundquist wire from the axillary artery. To ensure proper placement, angiograms were simultaneously performed during the delivery and deployment of the endograft, helped by a pigtail catheter placed in the transverse aortic arch from a right common femoral artery access. The endograft was placed so that it covered the dissection and the larger saccular aneurysm (Fig 2). The endograft was not postdilated due to the dissected thoracic aorta. A final angiogram confirmed no endoleak and full coverage of the saccular aneurysm and dissection. The endograft terminated distally with a 1-cm protrusion into the smaller aneurysm, which was not treated due to its relatively smaller size (Fig 3). The patient made a quick postoperative recovery and was discharged the next day with a small axillary hematoma, which resolved quickly. A computed tomography scan at 1 month showed no change in aneurysm size.
DISCUSSION Unfavorable iliac anatomy is a significant hindering factor for endovascular aneurysm repair (EVAR) of the aorta.1 Tortuous vessels, stenosis, or occlusion of the aortic bifurcation, the iliac arteries, or the small iliac vessels can make the retrograde approach for thoracic EVAR
(TEVAR) difficult to impossible. The European Collaborators on Stent-Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry reports that up to 13% of patients exhibit poor anatomic configuration or occlusive disease, which makes them poor candidates for EVAR.2 TEVARs using a carotid artery access have been reported by Heidenrich et al3 and Ghosh et al.4 The primary advantage for the left carotid approach is the favorable angle for wire delivery to the descending thoracic aorta, especially for type I aortic arches. There are also examples by Probst et al5 and Wudel et al6 of stent graft repair of thoracic artery aneurysms using the right axillary approach for endograft repair of the descending thoracic aorta. Ghosh et al4 also demonstrated the reverse loading technique for an aortouniiliac endograft that was custom designed for antegrade delivery. The main difference in this patient was that the stent graft was an unmodified device that was reverse-loaded into the Talent delivery system. Ghosh et al4 reported the reverse-loading technique for a custom device. The device used in this procedure was designed for retrograde delivery; however, preprocedure deployment and reverse-loading, as shown here, is an effective alternative to stent grafts designed for retrograde delivery. The carotid approach has a potential to impair blood flow to the brain. Heidenreich et al3 reported a stroke that resolved quickly within the postoperative period. This potential makes the axillary approach appear more favorable than the carotid approach. The risk of stroke for all TEVAR of descending thoracic aorta aneurysms is well documented.7 Roselli et al8 reported four patients with antegrade TEVAR of the ascending thoracic aorta; however,
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Fig 3. Illustration shows of the full deployment of the Talent endograft over the saccular aneurysm, terminating in the distal aneurysm with distal stents visible.
Fig 2. Illustration shows the deployment of the Talent endograft with distal stents visible.
their sample size was not quite adequate to demonstrate the safety and efficacy of the antegrade approach compared with the safety and efficacy of the retrograde approach. Wudel et al6 believed that a Dacron conduit access of the axillary artery was required due to the artery’s relatively small size. However, Probst et al5 concluded that the conduit might not be needed. The antegrade approach in our patient traversed through a type I aortic arch; however, going through a type II or type III aortic arch, although potentially more difficult, is not precluded by this approach. Probst et al,5 indeed, reports successful treatment in a patient with a type III aortic arch. Type II or III aortic arches make the carotid approach significantly more difficult and perhaps unsafe. Other arteries to consider include the left axillary, subclavian, or innominate arteries. It is
conceivable that a patient’s anatomy may allow for more favorable TEVAR through these arteries; however, antegrade TEVAR through these arteries has not been reported. We chose the Talent stent graft due to its length and geometry; however, we reasoned that its bare metal flared end in this patient’s smaller supraceliac aneurysm might possibly erode the aneurysm wall or impinge on the protruding pre-existing stents. Thus, we reversed the endograft to keep the bare metal proximal and the covered end of the endograft distal. The smaller aneurysm was not repaired because it was close to the previous renal and celiac artery stenting and was relatively small. CONCLUSIONS This case demonstrates the efficacy of the reverseloading technique for an unmodified stent graft using the right axillary artery approach. This technique opens up other possibilities for patients for whom endovascular repair would be preferred.
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The authors would like to acknowledge Julia F. Chen for providing all three illustrations. REFERENCES 1. Murray D, Ghosh J, Khwaja N, Murphy MO, Baguneid MS, Walker MG, et al. Access for endovascular aneurysm repair. J Endovasc Ther 2006; 13:754-61. 2. Cuypers PW, Laheij RJ, Buth J. Which factors increase the risk of conversion to pen surgery following endovascular abdominal aortic aneurysm repair? The EUROSTAR collaborators. Eur J Vasc Endovasc Surg 2000;20:183-9. 3. Heidenrich MJ, Neschis DG, Costanza MJ, Flinn WR. Endovascular repair of a penetrating thoracic aortic ulcer by way of the carotid artery. J Vasc Surg 2003;38:1407-10. 4. Ghosh J, Murray D, Farquharson F, Serracino-Inglott F. Abdominal aortic aneurysm repair: the carotid approach. J Vasc Surg 2009;49:763-6.
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5. Probst C, Esmailzadeh B, Schiller W, Wilhelm K. Emergent antegrade endovascular stent placement in a patient with perforated Stanford B dissection via right axillary artery. Eur J Cadiothorac Surg 2008;33: 1148-9. 6. Wudel JH, Williams JB. Right axillary artery conduit for antegrade deployment of a thoracic aortic endoprosthesis. J Thorac Cadiovsc Surg 2008;135:436-7. 7. Gutsche JT, Cheung AT, McGarvey ML, Moser WG, Szeto W, Carpenter JP, et al. Risk factors for perioperative stroke after thoracic endovascular aortic repair. Ann Thorac Surg 2007;84:1195-200. 8. Roselli EE, Soltesz EG, Mastracci T, Svensson LG, Lytle BW. Antegrade delivery of stent grafts to treat complex thoracic aortic disease. Ann Thorac Surg 2010;90:539-46.
Submitted Aug 26, 2010; accepted May 5, 2011.