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Treatment of an Iatrogenic Infrarenal Aortic Dissection Using a Unibody Endograft
1576
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Letters to the Editor
embolized with 8–15-mm-diameter coils 1 week after TEVAR. The patient tolerated all the procedures well, and the 3-year follow-up was uneventful. CT obtained 2.5 years after TEVAR showed no growth in the diameter of the descending thoracic aorta and preservation of flow into the mesenteric and renal arteries. A type II endoleak through an intercostal artery was present (Fig 3). The maximum diameter of the descending thoracic aorta had remained at 48 mm, the same as the preoperative measurement. The efficacy of TEVAR for the treatment of chronic dissection is controversial (1). Although favorable remodeling and complete elimination of the false lumen is achievable with TEVAR in acute aortic dissection, remodeling is poor in some patients with chronic dissection (2). It is not uncommon that a thoracoabdominal aortic aneurysm develops even after TEVAR in such patients. Generally, development of a thoracoabdominal aortic aneurysm is attributed to the blood flow coming from the re-entry into the false lumen (1). In the patient described here, there was great concern about the development of a thoracoabdominal aortic aneurysm because a large reentry was intentionally created just above the proximal anastomotic site of abdominal aortic replacement. Another issue with TEVAR for chronic dissection is intimal injury at the distal end of the stent graft. As mentioned earlier, because remodeling of the true lumen can be poor in patients with chronic dissection, there is a potential risk of intimal injury (3). The minimum diameter of commercially available stent grafts is 21 mm, whereas the diameter of the true lumen of the descending thoracic aorta was 11–12 mm in the present patient. Therefore, oversizing of the stent graft would be approximately 200% in the case of normal TEVAR, and this was considered sufficiently large to create intimal injury. Landing of the device in the false lumen of the distal descending thoracic aorta may avoid the aforementioned problems associated with conventional TEVAR. Because the distal end of the device was placed in the false lumen, which potentially dilates, the possibility of developing of a thoracoabdominal aortic aneurysm still remains in the present patient. However, 3-year follow-up did not show any sign of such a complication. Although the risk of intimal injury has not been completely eliminated, it would be much lower than in normal TEVAR because oversizing at the distal end of the stent graft was 110% in the present patient. Cases like the present one in which there is a large entry and a large re-entry are quite rare, and the findings cannot be applied to most cases of chronic dissection. However, our success may support the strategy described by Roselli et al (4) in which a fenestration is created at the distal descending thoracic aorta and the distal part of the stent graft is placed at the fenestrated segment.
Chahwala et al
’
JVIR
REFERENCES 1. Kang WC, Greenberg RK, Mastracci TM, et al. Endovascular repair of complicated chronic distal aortic dissections: Intermediate outcomes and complications. J Thorac Cardiovasc Surg 2011; 142:1074–1083. 2. Kusagawa H, Shimono T, Ishida M, et al. Changes in false lumen after transluminal stent-graft placement in aortic dissections: six years’ experience. Circulation 2005; 111:2951–2957. 3. Chino S, Kato N, Shimono T, Takeda K. Intimal tear after endovascular repair of chronic type B aortic dissection. Ann Thorac Surg 2009; 88:2029–2031. 4. Roselli EE, Sepulveda E, Pujara AC, Idrees J, Nowicki E. Distal landing zone open fenestration facilitates endovascular elephant trunk completion and false lumen thrombosis. Ann Thorac Surg 2011; 92:2078–2084.
Treatment of an Iatrogenic Infrarenal Aortic Dissection Using a Unibody Endograft From: Veer Chahwala, MD Samuel Golpanian, MD Jane K. Yang, MD Xiaoyi Li, MD Lee J. Goldstein, MD Arash Bornak, MD Vascular and Endovascular Surgery University of Miami Hospital, University of Miami Miller School of Medicine 1295 NW 14th Street, South Building, Suite J Miami, FL 33136
Editor: We report the endovascular treatment of an iatrogenic retrograde iliac artery dissection involving the infrarenal aorta with aortic occlusion and acute limb ischemia. A unibody endograft was successfully deployed in the infrarenal aorta allowing endovascular anatomic revascularization with preservation of the aortic bifurcation and exclusion of the false lumen. Institutional review board exemption was obtained to publish this report. A 45-year-old, morbidly obese woman (body mass index 48.4) was referred for acute limb ischemia after an aborted uterine fibroid embolization through a right common femoral artery access. Angiography performed during the uterine fibroid embolization revealed an occluded aorta (Fig, a) with no iliac artery flow. The angiogram indicated that the operator had reached the true aortic lumen, and there was at least one fenestration at the aortic reentry point. The catheter and sheath were removed before immediate referral. Subsequent physical examination revealed absence of a right femoral artery pulse and an intermittent left femoral pulse, suggesting a dynamic aortic dissection flap. An endovascular revascularization using an endograft was considered. Given the nature of the dissection involving the aorta with multiple fenestrations, treating the entire aortic intimal flap was deemed necessary to
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.04.021
Volume 26
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Number 10
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October
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2015
1577
Figure. (a) Angiogram performed at the initial procedure shows a catheter in the aortic lumen, an occluded aorta, and reconstitution of bilateral external iliac artery (EIA) and internal iliac artery (IIA). The catheter is in the lumen through a fenestration at the aortic level. (b) Dissection flap extending from right CIA. (c) AFX Unibody Endograft. Note the unique pattern of endoskeleton covered by graft material. (d) Completion angiogram confirming successful deployment of endograft (Endo).
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Letters to the Editor
exclude the false lumen, reinforce the aortic wall, and reestablish arterial flow to the right limb. Aortography performed through a left femoral approach demonstrated the true lumen of the distal aorta in continuity with the left common iliac artery (CIA), internal iliac artery, and external iliac artery (EIA). The right CIA was occluded with reconstitution of the distal EIA and internal iliac artery. A 5-F Soft-Vu Omni Flush catheter (AngioDynamics, Inc, Queensbury, New York) and an angled Glidewire (Terumo Medical Corp, Somerset, New Jersey) were used to access the right CIA and, after multiple attempts, were advanced into the true lumen of the right EIA. The Soft-Vu Omni Flush catheter was exchanged for an angled Glidecath (Terumo Medical Corp); angiography confirmed the catheter to be in the true lumen of the right EIA (Fig, b). The Glidewire was snared from the right side, after which an AFX Unibody Endograft (Endologix, Irvine, California) (Fig, c) was deployed from the left side. The endograft covered the entire infrarenal aortic flap, allowing anatomic revascularization of bilateral common iliac arteries. The right limb of the endograft was extended with a 9 mm 59 mm iCAST stent (Atrium Medical Corp, Hudson, New Hampshire) to cover the right CIA dissection flap and fenestration. Final angiography confirmed coverage of the dissection with preservation of the aortic bifurcation (Fig, d). Follow-up computed tomography angiography performed 4 months after the procedure demonstrated patency of the endograft, and adequate extremity perfusion was demonstrated on physical examination. At the 1-year follow-up examination, the patient was free of symptoms with palpable pedal pulses. Iatrogenic dissections typically result from entry of a wire or catheter into the intimal-muscularis plane, creating a dissection plane. The EIA is particularly vulnerable to iatrogenic dissections (1) during retrograde access to the aorta and under excessive dilation, such as with balloon angioplasty or advancement of large-caliber sheaths. The tear leads to pressurized flow between the arterial layers creating two arterial lumens. The newly created false lumen may travel in an anterograde or a retrograde direction. Complex retrograde dissections may extend to the aorta, resulting in complete aortic occlusion and acute end-organ ischemia, including catastrophic visceral ischemia. These dissections are more difficult to treat because multiple fenestrations may be present, and reestablishing anterograde anatomic flow requires locating the true aortic lumen and excluding fenestrations. A chronically weak arterial wall can progress to aneurysms. Placement of a bare metal stent is typically enough to cover small focal intimal flap tears in the first-order or second-order branch of the aorta, but stent grafts are considered for complex reentry dissections, especially in large vessels such as the aorta (2). Complete exclusion of the false lumen has been hypothesized to lead to better
Bosch et al
’
JVIR
results than both fully and partially patent false lumen, notably by preventing subsequent aneurysm formation (3). Thoracic endovascular aortic endograft placement for uncomplicated and complicated type B aortic dissection was developed over the last decade and has become a widely accepted treatment (4). In this case report, a catastrophic iatrogenic ilioaortic injury was treated successfully by endovascular means. The left iliac arteries were intact and allowed access to the true lumen of the aorta. The latter was in continuity to the right CIA, and wire manipulation through fenestrations reached the true lumen of the right EIA. Alternatively, when EIA reentry is unsuccessful, an intravascular ultrasound–guided reentry catheter such as the Pioneer Plus Catheter (Volcano Corp, San Diego, California) can be used to access the true EIA lumen. This technique allowed anterograde anatomic revascularization with preservation of the aortic bifurcation and coverage of fenestration. The endograft reinforced the weakened aortic wall and prevented longterm degeneration into an aneurysm. This endovascular approach proved to be a reliable alternative to an extraanatomic bypass or direct aortic surgery for a high-risk obese patient.
REFERENCES 1. Tonnessen BH. Iatrogenic injury from vascular access and endovascular procedures. Perspect Vasc Surg Endovasc Ther 2011; 23:128–135. 2. Kouvelos GN, Vourliotakis G, Arnaoutoglou E, et al. Endovascular treatment for isolated acute abdominal aortic dissection. J Vasc Surg 2013; 58: 1505–1511. 3. Tsai TT, Evangelista A, Nienaber CA, et al. Partial thrombosis of the false lumen in patients with acute type B aortic dissection. N Engl J Med 2007; 357:349–359. 4. Golledge J, Eagle KA. Acute aortic dissection. Lancet 2008; 372:55–66.
Nonoperative Management of Spontaneous Splenic Rupture in a Patient with Light-Chain Amyloidosis: A Case Report From: Nicholas Bosch, MD Anne S. Renteria, MD Karen Quillen, MD Dina Brauneis, NP John Santilli, MD Ducksoo Kim, MD Vaishali Sanchorawala, MD Amyloidosis Center (N.B., A.S.R., K.Q., D.B., V.S.) and Department of Radiology (J.S., D.K.) Boston University School of Medicine Boston Medical Center 820 Harrison Ave., FGH 1007 Boston, MA 02118
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.04.028
’
Letters to the Editor
embolized with 8–15-mm-diameter coils 1 week after TEVAR. The patient tolerated all the procedures well, and the 3-year follow-up was uneventful. CT obtained 2.5 years after TEVAR showed no growth in the diameter of the descending thoracic aorta and preservation of flow into the mesenteric and renal arteries. A type II endoleak through an intercostal artery was present (Fig 3). The maximum diameter of the descending thoracic aorta had remained at 48 mm, the same as the preoperative measurement. The efficacy of TEVAR for the treatment of chronic dissection is controversial (1). Although favorable remodeling and complete elimination of the false lumen is achievable with TEVAR in acute aortic dissection, remodeling is poor in some patients with chronic dissection (2). It is not uncommon that a thoracoabdominal aortic aneurysm develops even after TEVAR in such patients. Generally, development of a thoracoabdominal aortic aneurysm is attributed to the blood flow coming from the re-entry into the false lumen (1). In the patient described here, there was great concern about the development of a thoracoabdominal aortic aneurysm because a large reentry was intentionally created just above the proximal anastomotic site of abdominal aortic replacement. Another issue with TEVAR for chronic dissection is intimal injury at the distal end of the stent graft. As mentioned earlier, because remodeling of the true lumen can be poor in patients with chronic dissection, there is a potential risk of intimal injury (3). The minimum diameter of commercially available stent grafts is 21 mm, whereas the diameter of the true lumen of the descending thoracic aorta was 11–12 mm in the present patient. Therefore, oversizing of the stent graft would be approximately 200% in the case of normal TEVAR, and this was considered sufficiently large to create intimal injury. Landing of the device in the false lumen of the distal descending thoracic aorta may avoid the aforementioned problems associated with conventional TEVAR. Because the distal end of the device was placed in the false lumen, which potentially dilates, the possibility of developing of a thoracoabdominal aortic aneurysm still remains in the present patient. However, 3-year follow-up did not show any sign of such a complication. Although the risk of intimal injury has not been completely eliminated, it would be much lower than in normal TEVAR because oversizing at the distal end of the stent graft was 110% in the present patient. Cases like the present one in which there is a large entry and a large re-entry are quite rare, and the findings cannot be applied to most cases of chronic dissection. However, our success may support the strategy described by Roselli et al (4) in which a fenestration is created at the distal descending thoracic aorta and the distal part of the stent graft is placed at the fenestrated segment.
Chahwala et al
’
JVIR
REFERENCES 1. Kang WC, Greenberg RK, Mastracci TM, et al. Endovascular repair of complicated chronic distal aortic dissections: Intermediate outcomes and complications. J Thorac Cardiovasc Surg 2011; 142:1074–1083. 2. Kusagawa H, Shimono T, Ishida M, et al. Changes in false lumen after transluminal stent-graft placement in aortic dissections: six years’ experience. Circulation 2005; 111:2951–2957. 3. Chino S, Kato N, Shimono T, Takeda K. Intimal tear after endovascular repair of chronic type B aortic dissection. Ann Thorac Surg 2009; 88:2029–2031. 4. Roselli EE, Sepulveda E, Pujara AC, Idrees J, Nowicki E. Distal landing zone open fenestration facilitates endovascular elephant trunk completion and false lumen thrombosis. Ann Thorac Surg 2011; 92:2078–2084.
Treatment of an Iatrogenic Infrarenal Aortic Dissection Using a Unibody Endograft From: Veer Chahwala, MD Samuel Golpanian, MD Jane K. Yang, MD Xiaoyi Li, MD Lee J. Goldstein, MD Arash Bornak, MD Vascular and Endovascular Surgery University of Miami Hospital, University of Miami Miller School of Medicine 1295 NW 14th Street, South Building, Suite J Miami, FL 33136
Editor: We report the endovascular treatment of an iatrogenic retrograde iliac artery dissection involving the infrarenal aorta with aortic occlusion and acute limb ischemia. A unibody endograft was successfully deployed in the infrarenal aorta allowing endovascular anatomic revascularization with preservation of the aortic bifurcation and exclusion of the false lumen. Institutional review board exemption was obtained to publish this report. A 45-year-old, morbidly obese woman (body mass index 48.4) was referred for acute limb ischemia after an aborted uterine fibroid embolization through a right common femoral artery access. Angiography performed during the uterine fibroid embolization revealed an occluded aorta (Fig, a) with no iliac artery flow. The angiogram indicated that the operator had reached the true aortic lumen, and there was at least one fenestration at the aortic reentry point. The catheter and sheath were removed before immediate referral. Subsequent physical examination revealed absence of a right femoral artery pulse and an intermittent left femoral pulse, suggesting a dynamic aortic dissection flap. An endovascular revascularization using an endograft was considered. Given the nature of the dissection involving the aorta with multiple fenestrations, treating the entire aortic intimal flap was deemed necessary to
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.04.021
Volume 26
’
Number 10
’
October
’
2015
1577
Figure. (a) Angiogram performed at the initial procedure shows a catheter in the aortic lumen, an occluded aorta, and reconstitution of bilateral external iliac artery (EIA) and internal iliac artery (IIA). The catheter is in the lumen through a fenestration at the aortic level. (b) Dissection flap extending from right CIA. (c) AFX Unibody Endograft. Note the unique pattern of endoskeleton covered by graft material. (d) Completion angiogram confirming successful deployment of endograft (Endo).
1578
’
Letters to the Editor
exclude the false lumen, reinforce the aortic wall, and reestablish arterial flow to the right limb. Aortography performed through a left femoral approach demonstrated the true lumen of the distal aorta in continuity with the left common iliac artery (CIA), internal iliac artery, and external iliac artery (EIA). The right CIA was occluded with reconstitution of the distal EIA and internal iliac artery. A 5-F Soft-Vu Omni Flush catheter (AngioDynamics, Inc, Queensbury, New York) and an angled Glidewire (Terumo Medical Corp, Somerset, New Jersey) were used to access the right CIA and, after multiple attempts, were advanced into the true lumen of the right EIA. The Soft-Vu Omni Flush catheter was exchanged for an angled Glidecath (Terumo Medical Corp); angiography confirmed the catheter to be in the true lumen of the right EIA (Fig, b). The Glidewire was snared from the right side, after which an AFX Unibody Endograft (Endologix, Irvine, California) (Fig, c) was deployed from the left side. The endograft covered the entire infrarenal aortic flap, allowing anatomic revascularization of bilateral common iliac arteries. The right limb of the endograft was extended with a 9 mm 59 mm iCAST stent (Atrium Medical Corp, Hudson, New Hampshire) to cover the right CIA dissection flap and fenestration. Final angiography confirmed coverage of the dissection with preservation of the aortic bifurcation (Fig, d). Follow-up computed tomography angiography performed 4 months after the procedure demonstrated patency of the endograft, and adequate extremity perfusion was demonstrated on physical examination. At the 1-year follow-up examination, the patient was free of symptoms with palpable pedal pulses. Iatrogenic dissections typically result from entry of a wire or catheter into the intimal-muscularis plane, creating a dissection plane. The EIA is particularly vulnerable to iatrogenic dissections (1) during retrograde access to the aorta and under excessive dilation, such as with balloon angioplasty or advancement of large-caliber sheaths. The tear leads to pressurized flow between the arterial layers creating two arterial lumens. The newly created false lumen may travel in an anterograde or a retrograde direction. Complex retrograde dissections may extend to the aorta, resulting in complete aortic occlusion and acute end-organ ischemia, including catastrophic visceral ischemia. These dissections are more difficult to treat because multiple fenestrations may be present, and reestablishing anterograde anatomic flow requires locating the true aortic lumen and excluding fenestrations. A chronically weak arterial wall can progress to aneurysms. Placement of a bare metal stent is typically enough to cover small focal intimal flap tears in the first-order or second-order branch of the aorta, but stent grafts are considered for complex reentry dissections, especially in large vessels such as the aorta (2). Complete exclusion of the false lumen has been hypothesized to lead to better
Bosch et al
’
JVIR
results than both fully and partially patent false lumen, notably by preventing subsequent aneurysm formation (3). Thoracic endovascular aortic endograft placement for uncomplicated and complicated type B aortic dissection was developed over the last decade and has become a widely accepted treatment (4). In this case report, a catastrophic iatrogenic ilioaortic injury was treated successfully by endovascular means. The left iliac arteries were intact and allowed access to the true lumen of the aorta. The latter was in continuity to the right CIA, and wire manipulation through fenestrations reached the true lumen of the right EIA. Alternatively, when EIA reentry is unsuccessful, an intravascular ultrasound–guided reentry catheter such as the Pioneer Plus Catheter (Volcano Corp, San Diego, California) can be used to access the true EIA lumen. This technique allowed anterograde anatomic revascularization with preservation of the aortic bifurcation and coverage of fenestration. The endograft reinforced the weakened aortic wall and prevented longterm degeneration into an aneurysm. This endovascular approach proved to be a reliable alternative to an extraanatomic bypass or direct aortic surgery for a high-risk obese patient.
REFERENCES 1. Tonnessen BH. Iatrogenic injury from vascular access and endovascular procedures. Perspect Vasc Surg Endovasc Ther 2011; 23:128–135. 2. Kouvelos GN, Vourliotakis G, Arnaoutoglou E, et al. Endovascular treatment for isolated acute abdominal aortic dissection. J Vasc Surg 2013; 58: 1505–1511. 3. Tsai TT, Evangelista A, Nienaber CA, et al. Partial thrombosis of the false lumen in patients with acute type B aortic dissection. N Engl J Med 2007; 357:349–359. 4. Golledge J, Eagle KA. Acute aortic dissection. Lancet 2008; 372:55–66.
Nonoperative Management of Spontaneous Splenic Rupture in a Patient with Light-Chain Amyloidosis: A Case Report From: Nicholas Bosch, MD Anne S. Renteria, MD Karen Quillen, MD Dina Brauneis, NP John Santilli, MD Ducksoo Kim, MD Vaishali Sanchorawala, MD Amyloidosis Center (N.B., A.S.R., K.Q., D.B., V.S.) and Department of Radiology (J.S., D.K.) Boston University School of Medicine Boston Medical Center 820 Harrison Ave., FGH 1007 Boston, MA 02118
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2015.04.028