and infrarenal aortic aneurysm using a combination of conventional surgery and endoluminal stent grafting. Introduction. Aneurysms of the thoracic aorta have ...
Langenbeck’s Arch Surg (2000) 385:27–30 © Springer-Verlag 2000
Tina U. Cohnert Ajay Chavan Thorsten Wahlers Frank Oelert Matthias Karck Michael Galanski Axel Haverich
Received: 19 April 1999; in revised form: 18 August 1999 Accepted: 20 August 1999 T.U. Cohnert (✉) · T. Wahlers · F. Oelert M. Karck · A. Haverich Department of Thoracic and Cardiovascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, D-30623 Hannover, Germany Tel.: +49-511-9063332 Fax: +49-511-9063460 A. Chavan, · M. Galanski Department of Diagnostic Radiology I, Hannover Medical School, Carl-Neuberg-Str. 1, D-30623 Hannover, Germany
O R I G I N A L A RT I C L E
Simultaneous treatment of thoracic and infrarenal aortic aneurysm using a combination of conventional surgery and endoluminal stent grafting
Abstract Introduction: Patients with multiple aortic aneurysms represent a small subgroup with the need for extensive surgical treatment at considerable risk. Endovascular treatment in combination with conventional operation is possible. We demonstrate a case with simultaneous exclusion of aneurysms of the descending thoracic and the infrarenal aorta to outline the technical obligations. Conclusion: Simultaneous exclusion of a thoracic and an abdominal aneurysm can be performed successfully by conventional infrarenal aortic replacement with bifurcat-
Introduction Aneurysms of the thoracic aorta have been treated by conventional surgical repair for the last 48 years [1, 2]. Despite a continuous improvement in techniques leading to a reduction in morbidity and mortality, there is still a considerable operative risk associated with the procedure of graft interposition, chiefly related to major thoracotomy. The postoperative complications include bleeding, paraplegia, stroke, renal insufficiency, and the necessity for prolonged respiratory support. The estimated incidence of thoracic aortic aneurysms is six cases per 100,000 person-years, mainly afflicting elderly male patients [3]. The frequent co-morbidities include arterial hypertension, coronary artery disease, and congestive heart failure. An additional infrarenal aortic aneurysm has been reported to occur in 10–20% of patients [4]. Without surgical treatment, the risk of rupture for thoracic aneurysms is high, with actuarial 1-year and 5-year survival rates of 60% and 20%, respectively [5, 6]. The operative mortality in large series range from 5% to 20% [6, 7].
ed dacron prosthesis and endovascular implantation of a thoracic stentgraft within one operation. Key words Aortic aneurysm · Combination therapy · Endovascular treatment
With the introduction of endovascular transluminal stent-graft repair for aortic aneurysms in 1986 by Volodos and in 1991 by Parodi, a less-invasive therapeutic alternative became available [8, 9]. In 1992, Dake started implantations of stent-graft protheses in patients with thoracic aneurysms [10]. His experience up until October 1997 includes 124 patients with an operative mortality of 9.0% and a paraplegia rate of 3.0% in a detailed report on 103 patients [11, 12, 13]. In Dake’s series, the incidence of paraplegia was 13.6% and of death 4.5% in 22 patients undergoing simultaneous repair of thoracic and abdominal aneurysms [12]. Worldwide, more than 194 cases of thoracic repair by stent-graft have been reported, demonstrating the technical feasibility with different indications. The number of patients with combined repair is smaller – 22 cases. Nevertheless, there are no long-term results on effectiveness to allow us to evaluate the procedure. However, combined approaches have been rare so far. It was the aim of this case report to outline the technical obligations when using this approach.
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Fig. 1 a Digital subtraction angiograms of the thoracic and abdominal aorta and of the pelvic vessels. The lumen of the bilobed infrarenal aneurysm is partially thrombosed. b The presence of the aneurysm can be inferred by the absence of opacification of the lumbar arteries. c Note the high-grade stenosis of the left common iliac artery and the narrow external iliac arteries
Fig. 2 Preoperative computed tomography (CT) of the thoracic aneurysm (a) showing a diameter of 6.36 cm. In control, 9 months after stent-graft implantation, the diameter is reduced to 5.63 cm (b)
Case report An 63-year-old-woman presented with a 1-year history of intermittent back pains. Her medical history included arterial hypertension and coronary artery disease without evidence of myocardial infarction. In addition, renal insufficiency was diagnosed 25 years prior to admission and chronic hemodialysis was instituted 5 months preoperatively, possibly due to analgesic nephropathy. Peripheral vasculopathy included occlusive disease of pelvic and limb vessels. Preoperative medication included antihypertensives, including beta-blockers. Physical examination revealed a blood pressure of 140/70 mmHg in both arms. There was a palpable pulsatile abdominal mass and palpable pulses in both groins. A spiral computed-tomography (CT) examination of the thoracic and abdominal aorta revealed a thoracic aneurysm with a maximal diameter of 5.9 cm, commencing 5.4 cm distal to the origin of the left subclavian artery and extending 2.8 cm distally. The thoracic aortic diameters proximally and distally were 29 mm and 28 mm, respectively (Fig.1a). Starting 20 mm infrarenally, a second bilobed aneurysm was seen with a maximal diameter of 4.7 cm. The aneurysm extended almost up to the aortic bifurcation (Fig. 1b). Angiography confirmed these findings. In addition, se-
Fig. 3 Spiral computed tomography (CT) angiograms (maximum intensity projections – MIPs) of the thoracic aneurysm before and 9 months after stent-graft implantation. Note the partially thrombosed lumen of the aneurysm (arrow) in a. At follow-up, complete thrombosis with minimal shrinkage of the aneurysm can be seen in b
vere narrowing of the left common iliac artery was noted. The iliac vessels showed luminal diameters below 7 mm (Fig. 1c). Preoperative cardiac evaluation included cardiac catheterization showing two-vessel disease with occlusion of the right coronary artery and 50% stenosis of left anterior descending coronary artery. Thallium scintigraphy did not demonstrate perfusion defects under stress conditions, therefore medical treatment was continued. Treatment was deemed necessary for the thoracic aneurysm with a maximum diameter of 5.9 cm (Fig. 2a) and for the infrarenal aneurysm with a diameter of 4.78 cm (Fig. 3) because of the aneurysm’s size. Relating to the patients’ symptoms, the origin of the intermittent back pains could not be clearly differentiated be-
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Fig. 4 The infrarenal aortic aneurysm shows a diameter of 4.78 cm and partial thrombosis on preoperative computed tomography (CT)
tional operation was continued by completing the end-to-end anastomosis of the graft to the right common iliac artery and reperfusion of the right leg. Ischemia time for the left leg was 36 min, and for the right leg 115 min. Total operating time was 215 min. Intra- and postoperative courses were uneventful. The patient was transferred from the operating room to the intensive care ward, where ventilation was continued until vital signs were stable and the patient breathed spontaneously. At no point were neurological deficits or signs of peripheral microembolization recorded. On the first postoperative day, the patient was transferred to the normal ward. Symptoms of a post-implantation syndrome, such as fever, leucocytosis and elevated C-reactive protein, were not evident. On the 12th postoperative day, she was discharged home after an uneventful course. CT control on the ninth postoperative day demonstrated no evidence of perigraft perfusion aneurysm. The thoracic aneurysm was completely thrombosed. A spiral CT follow-up at 9 months showed complete thrombosis with shrinkage of the thoracic aneurysm. (Fig. 3b, Fig. 2b). Twelve months postoperatively, the patient is well without clinical complaints.
Discussion tween the thoracic aneurysm and the abdominal aneurysm. In the absence of neurologic symptoms and radiologic findings consistent with vertebral disease, the indication for exclusion of both aneurysms was given. Additionally, the eccentric shape of the infrarenal aneurysm in angiography confirmed our plan for aneurysm exclusion infrarenally. Treatment options were (1) conventional operations for both aneurysms as a staged procedure with primary thoracic aneurysm exclusion via thoracotomy and secondary laparotomy for infrarenal replacement, (2) a completely endovascular approach and (3) a combination procedure. Our initial plan was interventional transfemoral therapy of both aneurysms with exclusion by stent-graft implantation. However, due to both the narrow iliac vessels, which would not allow the introduction of the 27F system (9 mm), and the iliac stenosis on the left, the therapeutic strategy was modified to a combination approach with stenting of the thoracic aneurysm and conventional reconstruction of the infrarenal aorta. Preoperative tests made evident that to allow advancement of the thoracic system through a prosthetic limb, a 20×10-mm Dacron prosthesis was required – a rather unusual size for a 54-kg woman. Prior to surgery, a 5F pigtail catheter was introduced into the ascending aorta from the left brachial approach. At the time of operation, the abdominal aorta was exposed through a midline incision. The aorta appeared normal in the suprarenal segment and immediately distal to the renal artery origins. The inferior mesenteric artery did not show a palpable pulse. Proximal anastomosis was performed in typical end-to-end fashion after trans-section of the infrarenal aorta with the 20×10-mm bifurcated double velour-knitted vascular graft. Thereafter, the graft was anastomosed end-toend to the left common iliac artery and perfusion to the left leg was reinstituted. The stent-graft system was introduced over a super-stiff guide wire (Amplatz 3 super stiff 0.035 in Medi-tech, Boston Scientific Corporation, Watertown, USA) through the right prosthetic limb and advanced to the thoracic aorta. Under fluoroscopy, the thoracic stent-graft (Talent Endoluminal Graft, World Medical Manufacturing Corporation, Sunrise, Fla.) was placed immediately distal the origin of the left subclavian artery. Stent-graft diameter was 34 mm; total graft length 110 mm, with 15-mm bare springs proximally and distally. There were no technical difficulties with stent positioning or deployment. During deployment, arterial blood pressure was temporarily lowered to a maximal systolic value of 60 mmHg. After extraction of the introducer system, the conven-
Treatment of infrarenal abdominal aortic aneurysms by transluminal implantation of an endovascular stent-graft has gained widespread clinical application despite the lack of long-term results. Soon after introduction of the endovascular techniques, the Stanford group applied this technology to numerous patients with aneurysms of the thoracic aorta [8, 9, 10]. In our patient, complete endovascular treatment of both thoracic and infrarenal aneurysms was not possible due to the narrow diameter of the iliac vessels. Mitchell encountered the same problem in his overall thoracic patients [12]. A transfemoral advance of the thoracic prosthesis was performed in 52%. In 20% of patients, a retroperitoneal approach was necessary after a failed transfemoral access. In 22 patients, a concomitant abdominal aortic aneurysm repair was performed as in our patient. This approach gives the advantage of good control of bleeding with introduction of the large sheath leading to minimal blood loss. In addition, it rules out possible complications due to sheath length. This brachial line is recommended by Dake’s group and enhances security of the procedure. In our experience, it gives the additional possibility of angiography post-implantation [12, 13]. To improve exact deployment of the stent proximally and prevent dislocation during balloon inflation, Mitchell recommends lowering of the mean systemic arterial blood pressure by the anesthesiologist to a maximum of about 50 mmHg by administration of vasodilators or beta-blockers [4]. Different groups have advocated induction of ventricular fibrillation or an intentional asystole by adenosine during the phase of stent deployment [14, 15]. In our patient, we did not see the necessity for major cardiac manipulation. Stent deployment was uneventful and in the planned position, with a lowered systemic blood pressure to a maximal systolic value of 60 mmHg for 2 min.
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Intraoperative hemodynamic manipulations are associated with the risk of postoperative complications. The Stanford group saw four instances of paraplegia in 108 patients (3.7%). This rate appears lower than in conventional thoracic aneurysm surgery (3.5–5.5%) [3, 6, 12]. From available data, it is difficult to determine which factors definitely cause spinal cord ischemia in a multifactorial setting. Our patient did not show any signs of neurological deficit in her postoperative course. The decision for endovascular treatment in her was based on the severe co-morbidities, including coronary artery disease and renal insufficiency with chronic hemodialysis, although operability for a staged conventional surgical therapy would have been given. Now that technical feasibility of thoracic stent graft placement has been demonstrated in about 200 patients worldwide, the question arises which patients benefit the most from this treatment. The avoidance of a major thoracotomy in multimorbid elderly patients showed advantages regarding mortality and morbidity relative to conventional repair. In the first report, in 1994, there was no mortality in 13 patients compared with 13% with open repair [5]. The 1997 report included 108 patients with a 30-day mortality of 9.3% (10/108 patients) and 2 late deaths [12]. Mitchell also reported that 50% of stented patients were not eligible for conventional repair due to their accompa-
nying disease, mainly chronic obstructive disease, congestive heart failure, and partially due to multiple previous thoracotomies. In this group of patients with no treatment alternative, the indication for endovascular procedures is clear. The situation for patients suited for conventional operation is more difficult and the question of the best therapeutic option cannot be answered clearly with the available data. Problems are the lack of longterm results and occurrence of technical failures in endovascular implants including aneurysm rupture leading to late deaths despite technically correct primary treatment and complete aneurysm thrombosis [12]. The longest follow-up reported from Stanford averages 21.8 months (range 1–64 months). A total of 53% of patients were free from treatment failure at 3.7 years postoperatively. Our patient is still alive and well 9 months postoperatively. With the help of our case, we would like to illustrate a technically feasible method for the treatment of multilevel aneurysmatic disease in multi-morbid patients who are at high risk for thoracotomy. The long-term efficacy of thoracic stent-graft systems for aneurysm exclusion has yet to be established. Therefore, routine use of this therapy cannot be recommended without further experience and studies.
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