Accepted Manuscript Complete endovascular treatment of saccular aneurysm of the aortic arch by coiling and ch-EVAR Sebastiaan Martens, MD, Lieven Maene, MD, Roel Beelen, MD PII:
S0890-5096(15)00496-3
DOI:
10.1016/j.avsg.2015.03.062
Reference:
AVSG 2414
To appear in:
Annals of Vascular Surgery
Received Date: 3 January 2015 Revised Date:
15 March 2015
Accepted Date: 30 March 2015
Please cite this article as: Martens S, Maene L, Beelen R, Complete endovascular treatment of saccular aneurysm of the aortic arch by coiling and ch-EVAR, Annals of Vascular Surgery (2015), doi: 10.1016/ j.avsg.2015.03.062. 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
Co mp let e endova scular t reat me nt o f sac cular aneu r ys m o f the ao rtic a rch b y coiling and ch -E V AR
Corresponding Author: Dr. Sebastiaan Martens, MD
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Corresponding Author's Institution: OLV Clinic Aalst Cardiovascular and thoracic surgery Moorselbaan 164 9300 Aalst Belgium
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S EBAS T IAAN M AR TENS - LIEVEN M AENE - R OE L BEE LEN
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First Author: Sebastiaan Martens, MD Department of Cardiovascular an Thoracic Surgery OLV Clinic Aalst Moorselbaan 164 9300 Aalst Belgium [email protected] Tel.: 0032 (0)53/72.45.99
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Order of Authors: Sebastiaan Martens, MD, Lieven Maene, MD, Roel Beelen, MD
ACCEPTED MANUSCRIPT ABS TR AC T S accul ar aneur ys m of t he aort i c a rch i s a condi t i on wi t h a hi gh as s o ci at ed m ort al i t y. Open s u rger y i s oft en com pl i cat ed wi t h poor out com e and hi gh pos t operat i ve m orbi di t y and m ort al i t y. In t hi s cas e repo rt
we des cri be an
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al t ernat i ve s t epwi s e endovas cul a r r epai r: coi l i ng of t he an eur ys m fol l owed b y coveri n g of t he os t i um of t he s accul ar aneur ys m b y ch-EV AR . In our opi ni on t hi s t echni que coul d be an al t ernat i v e for a ful l y cus t om i z ed branched o r
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fenes t rat ed endopro s t hes i s t o t reat t hes e ki nd of aneur ys m s .
ACCEPTED MANUSCRIPT IN TR ODUC T IO N A s accul a r aneu r ys m of t he aort i c ar ch i s a pos s i bl e l i fe t hreat eni n g condi t i o n. The y a re t radi t i on al l y t reat ed b y o pen s urger y.
S urge r y p erfo rm ed fo r
corre ct i on of an eur ys m s of t he aort i c arch i s o ft en co m pl i cat ed wi t h poor (1,2,3)
.
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out com es and a hi gh pos t operat i ve m orb i di t y and m ort al i t y
S i nce 1991 endovas cul ar t herap y has b een em er gi n g as an effect i ve and l es s i nvas i ve t reat m ent for aort i c aneu r ys m s .
M ore a nd m ore cas e report s can b e
found about t he us e of endopros t hes i s i n aort i c pat hol o g y wi t h di ffi cul t l andi ng The us e of branched gr aft s , fenes t rat ed gr aft s , chi m ne y gr aft s and
occl uder d evi ces i s m ore and m ore ac ce pt ed
(2)
.
SC
z ones .
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In t hi s r eport w e de s cri be a cas e of a s accul a r an eur ys m of t he aort i c arch t h at was s ucces s ful l y t r e at ed b y coi l i ng of t he l um en com bi ned wi t h a chi m ne y s t en t t o debran ch t e l eft c arot i d art er y and a s econd s nork el s t ent t o debran ch t he l eft
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s ubcl avi an art er y. To our knowl ed ge, t hi s i s t he fi rs t cas e publ i s hed.
ACCEPTED MANUSCRIPT C AS E R EP OR T W e report a cas e of a 72 - yea r ol d pat i ent wi t h an a cci den t al l y found s a ccul a r aneur ys m of t he aor t i c arch ( Fi g. 1). The m edi cal hi s t or y of our p at i ent was s i gni fi c ant for C OP D, AHT, l ung
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em bol i s m , pros t at e carci nom a wi t h rob ot i c res ect i on, end s t age ki dne y di s eas e wi t h hem odi al ys i s a nd s ucces s ful ki dne y t rans pl ant at i on i n 2007.
He had no com pl ai n t s and was com pl et e as ym pt om at i c of t h e aneur ys m . Ther e was a norm al ph ys i cal ex am i nat i on. In l aborat or y eval uat i on, whi t e bl ood cel l
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count and C -re act i v e prot ei n (C R P ) l evel were no rm al .
C om put ed t om ograp h y s can (C T-s c an) of t horax and abdo m en was per form ed Thi s C T-s c an s hows a s a ccul a r
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due t o an epi s ode o f fev er of unkno wn caus e.
aneur ys m of t he aor t i c arch wi t h a s hort neck and a part i al l y t h rom bos ed l um en wi t h a cros s s ect i on al di am et er o f 53 m m (Fi g.1).
The an eur ys m was l o cat ed
near t o t he os t i um of t he l eft s ubcl avi an art er y.
In fect i ous o ri gi n e o f t he aneur ys m was rul ed out b y m ul t i pl e bl oodcul t ures and
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P os i t ron em i s s i on Tom ograp h y s can (P ET-s can). Bec aus e of t h e m e di cal hi s t or y and t he as ym pt om at i c c ours e of our pat i en t , cons ervat i ve t r eat m ent was undert ak en i ni t i al l y.
How ever, t he an eur ys m
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enl ar ged on cons e cu t i ve C T-s can s o t reat m ent becam e m and at or y. B ene fi t s and ri s ks of t he di ffe ren t t reat m ent opt i ons were cons i der ed an d di s cus s ed wi t h our
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pat i ent .
Bec aus e o f t he m edi cal hi s t or y and t h e hi gh m orbi di t y and m ort al i t y of t h e ope n repai r
we
pref err ed
a
s t epwi s e
co m pl et e
endovas cul ar
appro ach
by
a
com bi nat i on of coi l em bol i z at i on and chi m ne y Thora ci c endovas cul a r Aort i c R epai r (ch-TE VAR ) .
H yb ri d s urgi c al debranchi n g pro ced ures m a y
di m i ni s h
s om e of t he bene fi t s of endov as cul a r s ur ge r y, es p eci al l y i n pat i ent s wi t h s eve re com orbi di t y. Bec aus e o f t he con t ras t l oad and t he durat i on of t he pro cedure, a s t epwi s e approach w as pr efe rred i n our pat i ent wi t h hi s t or y of a ki dne y t rans pl ant at i on and cardi ac fai l ur e. M oreover t he e ffi c ac y and dur abi l i t y o f each s t ep al on e i n aort i c s ac cul ar aneu r ys m s i s not cl ea r fo r t he m om ent .
ACCEPTED MANUSCRIPT
The fi rs t s t age i n ou r s t epwi s e approa ch was percut anous co i l i ng of t he s accul ar aneur ys m .
The pro cedure w as perfo rm ed under gene ral an es t hes i a, wi t h 5000
IU of hep ari n gi ve n s ys t em i cal l y. ri ght f em oral a rt er y.
A 6 Fren ch
s he at h w as i nt roduced i n t h e
W i t h t he us e of a S i m m ons 1 cat het er (Terumo Medical
Corporation, Somerset, New Jersey) t he a neur ys m was ac ce s s ed.
A P ro gre at
m i crocat het e r (T eru m o Medical Corporation, Somerset, New Jersey) was advan ced i n
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t he aneu r ys m al c avi t y. Fi rs t t o cr eat e a m at ri x , a 3D- fram i ng coi l 20m m x 50cm (Terum o Az ur Fr am i ng coi l , T erum o Medical Corporation, Somerset, New Jersey) was pl aced i n t h e an eu r ys m .
Aft e rwa rds t hi s m at ri x was f i l l ed
wi t h s eve ral
det achabl e coi l s (20m m x 30 cm , 15m m x 30cm , 15mm x 20cm ) (Terum o A ZUR
SC
P eri pheral H ydroC o i l Em bol iz at i on S ys t em , Terum o Medical Corporation, Somerset, New Jersey) . C ont rol angi o gr am peroper at i ve s hows com pl et e t hrom bos i s of t he The proce dure was unevent ful l and t he pat i ent was
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aneur ys m (Fi g. 2) ( Fi g. 3).
di s char ged f rom t he hos pi t al 2 da ys a ft e r t he oper at i on.
The s econd s t a ge, ch-TEVAR - repai r w as s chedul ed 2 we e ks l at er. Tr eat m ent obj ect i ve
w as
ful l
cover a ge
of
the
s ac cul ar
aneu r ys m
by
a
t hor aci c
endopros t hes i s and endovas cul a r deb ran chi ng of t h e l e ft co m m on carot i d art er y b y a chi m ne y-t echn i que and endovas cu l ar debran chi n g of t he l eft s ubcl avi an
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art er y b y a pe ri s cop e t echni que (Fi g. 4 ) .
B ecaus e of a w orki ng art eri ov enous
fi s t ul a i n t he l eft arm , revas cul ari s at i on of t he l eft s ubcl avi an art e r y was m andat or y.
M oreover rec ent evi dence has s hown an i ncreas e i n neurol o gi c
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m orbi di t y wi t hout revas cul a ri z at i on of t he l eft s ubcl avi an ar t er y. B y a s m al l cut -do w n i n t he bas e of t he neck a 8 F rench s h eat h w as i nt roduced ret ro grad e i n t he l eft com m on art er y and i t was deb r anched b y chi m ne y
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t echni que t owards t he as cendi n g ao rt a wi t h a Bent l e y- Inno m ed P eri pheral S t ent Graft S ys t em s t ent 8m m di am et er 57 m m l en gt h ( Bentley InnoMed, Hechingen, Germany).
Th e s ub cl avi an a rt er y was debranch ed wi t h a GOR E ® V IA BAHN ®
Endopros t hes i s of 10m m di am et er and 1 5 cm l engt h (Cook Medical, Bloomington, Ind) as a p eri s cop e gr af t t owards t he des c e ndi ng aort a. Thi s was done b y a 8 F r s heat h i n t he l eft gr oi n. W i t h al l gui de wi res i n pl a ce and bal l oons i nfl at ed i n t he chi m ne y and p eri s cope gr aft t he os t i um of t he s acc ul ar aneu r ys m w as covered wi t h a M e dt roni c Val i ant endopros t es i s of 36mm di am et er 150 mm l engt h (M edt roni c, Minneapolis, Minn) groi n.
i ns ert ed percut an e ous l e y b y t he ri ght
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Angi o gr aph y done i n t he end of t he pr ocedure s howed p at ent carot i d v es s el s ; pat ent l eft s ub cl avi an art er y an a t ot al ex cl us i on of t he s ac cul ar aneur ys m (Fi g. 4). The
pos t operat i ve
com pl i cat i on.
cours e
was
un event ful l ;
t here
were
no
neurol o gi c
Our pat i ent had a s hor t epi s ode of at ri al fi bri l l at i on but was
i n good cl i ni cal con di t i on t he hos pi t al .
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res t ored i nt o s i nus rh yt hm b y am i oda ron e. Fi ve da ys aft er t he operat i on he l eft
C ont rol C T-s can a ft er 6 and 12 m ont hs s hows no fl ow i n t he aneu r ys m al s ac, com pl et e t hrom bos i s of t he aneur ys m a l l um en and good pat enc y of bot h t h e
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chi m ne y and peri s co pe graft s t o t he s upr a-aort i c v es s el s .
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D IS C US S ION An art eri al aneu r ys m i s defi ned as a perm anent di l at a t i on b y 50% gre at er
fus i form t yp e, or t h e m ore r are s accul ar t ype Et hi ol ogy
of
s a cc ul ar
aneu r ys m s
is
(4)
.
vari ed,
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di am et er of t he nor m al ves s el . The y c an be cat e go ri z ed i nt o t he m ore com m on
i ncl udi n g
aort i c
i nfe ct i on,
s urger y
(5,6)
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degener at i on of a penet rat i n g at heros cl erot i c ul cer, t r aum a and previ ous aort i c .
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The com m on per cep t i on t hat t he nat ural hi s t or y of a s ac cul ar aneu r ys m i s m ore m al i gnant i s not pr oved and t he re al r i s k of rupt ure i n s a ccul ar aneu r ys m s i n unknown
(6)
. For a s accul a r an eur ys m o f t he ao rt i c ar ch op en s ur gi cal repai r i s
t oda y t he t reat m ent of choi ce, as s oci at e d wi t h hi gh m orbi di t y and m ort al i t y. In t he l as t 3 dec ades endovas cul a r m ana gem ent has be en i nc reas i n gl y be com e a n al t ernat i ve,
l es s i nvas i ve and eff ect i ve t reat m ent for a ort i c di s orders
(7)
.
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Howeve r for p at hol og y of t he ao rt i c a rch, conv ent i onal e ndovas cul ar s t ent i n g can be di ffi cul t bec aus e of t he di ffi cul t l andi ng z one and for pres ervi n g fl ow (2)
.
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i nt o t he s upra-aort i c ves s el s
S everal endov as cul ar t echni ques , i ncl u di ng coi l em bol i z at i on and endol um i nal s t ent gr aft s , have b een us ed s uc ces s ful l y.
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s m al l necked an eur ys m s .
C oi l s have bee n effe ct i ve us ed i n
Thi s t echni que c annot be pe rf orm ed i n fus i form
aneur ys m s , t he ane ur ys m m us t be s ac c ul ar, wi t h t he di am et er of t he s a c l ar ger t han t he ne ck t o e nabl e i nt ra- aneur ys m al coi l packi n g wi t hout ri s k of coi l di s pl acem ent
in
the
endovas cul a r opt i on
(7)
C om pl et e ex cl us i on of
art eri al
l um en .
S t ent -graft
ex cl us i on
is
anot her
. bl ood fl ow i n
t o t he aneur ys m i s es s ent i al .
Leak a ge
i nt o t he aneur ys m al s ac can r es ul t i n enl ar gem ent of t he aneur ys m al s ac and event ual l y rupt ure. In our pat i ent w e prefe rred a com bi ne d t echni que wi t h coi l em bol iz at i on and chi m ne y s t ent gr aft i ng be caus e of t h e l ocat i on of t he s ac c ul ar an eur ys m .
Th e
ACCEPTED MANUSCRIPT
neck of t he s a ccul a r aneur ys m was l oc at ed cl os e t o t he l e ft s ubcl avi an art e r y. The fi rs t s t ep of t he pro cedur e w as c oi l em bol i s at i on of t he aneur ys m . The s econd s t ep was pl acem ent of a t horaci c s t ent - gra ft , perfus i on of t he l eft s ubcl avi an art er y a nd t he l eft carot i d art er y was pres e r ved wi t hout s urgi c al b ypas s b y us i n g a c hi m ne y and s no rkel gr aft . Al t hough coi l i ng a nd chi m ne y s t ent graft i n g s epar at el y a re des cri b ed earl i e r ,
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t hei r com bi nat i on as a novel t reat m ent h as not been des cri be d before.
In s um m a r y, t hi s s t epwi s e proc edure i s a t echni c al l y f ea s i bl e, l es s i nvas i ve,
be
an
al t ern at i ve
for
ful l y
cus t o m i z ed
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durabl e and s a fe t r e at m ent for hi gh ri s k pat i ent s . The des c ri bed t echni que coul d branched
or
fenes t r at ed
aort i c
del i ver y i nt e rval .
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endopros t hes i s . Es peci al l y b ec aus e t ho s e gr aft s hav e a l ong produ ct i on and Durabi l i t y con cerns are s t i l l pres ent , l ong-t e rm fol l ow-up i s
ex cept i onal l y i m por t ant i n l i ght of t he i nt eract i ons of t he s t ent s , t he t horaci c endograft and t he a ort i c ar ch. At s ho rt -t erm fol l ow up our procedu re s eem s t o be eff ect i ve.
How e ver, l onger fol l ow up i s needed t o as s es s t he effi c ac y an d
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durabi l i t y.
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1.
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R EFER ENC ES M ul der EJ , Bockel H, M aas J . M orbi di t y and m o rt al i t y o f recons t ruct i ve s urger y o f noni nfec t ed fal s e aneur ys m s det ect ed l ong aft e r aort i c pros t het i c recons t ruct i on. A rch S urg 1998; 133: 45-9 .
Ohrl ander T., S ones s on B, Ivan cev K, R es ch T, Di as N, M al i na M .
SC
2.
The
C hi m ne y graft : A t echni que for pres e rv i ng or res cui i n g aor t i c branch ves s el s
3.
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i n s t ent gra ft s eal i n g z ones . J Endovas c Ther 2008; 15: 427- 32 Dake M D, M i l l er DC , S em ba C P , M it chel l R S , W al ker P J , Li ddel l R P . Trans l um i nal pl ace m ent of endovas cu l ar s t ent - gr aft s for t he t reat m ent o f des cendi n g
t hor aci c
aort i c
29; 331(26): 1729-34.
N
Engl
J
M ed.
1994
De c
J ohns t on KW , R ut herford R B, Ti l s on M D, S hah DM , Holl i er L, S t anl e y
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4.
aneur ys m s .
J C . S ugges t ed s t and ards fo r r eport i ng o n art e ri al an eur ys m s S ubcom m i t t ee on R eport i ng S t and ards for Art e ri al An eur ys m s , Ad Hoc C om m i t t ee on R eport i n g S t andards , S oci et y for Vas cul a r S urge r y and Nort h
Am eri can C hapt e r,
5.
EP
Int e rnat i onal S oci et y fo r C ardi ovas cul ar S urge r y. J Vas c S urg 1991; 13: 452-8. Kam pm ei er R .H. S accul ar an eur ys m of t he t horaci c ao rt a: a cl i ni cal s t ud y
6.
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of 633 cas es . Ann Int ern M ed. 1938; 12( 5): 624-651 Eri c K. S han g, M D ,a De rek P . N at han , M D,a W i l l i am W . Boonn, M D,b Iv an A. Lys -Dobr a di n,a R onal d M . Fai rm an, M D,c Edwar d Y. W oo, M D A m odern ex peri enc e wi t h s accul ar aort i c aneur ys m s J VAS C S urg 2013; 57: 84-8 7.
R akes h P . P at el , Athanas i os Kat s ar g yri s , Eri c L. G. Verho even, Donal d J . Adam , J ohn A. Har dm an Endovas cul ar aort i c aneu r ys m re pai r wi t h chi m ne y and s norkel gra ft s : i ndi cat i ons , t echni ques and res ul t s . C ardi oVas cul ar and Int e rvent i onal R adi ol og y De cem be r 201 3, Vol um e 36, Is s u e 6, pp 1443-1451
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Fi gu re 1.
P reoperat i ve C T s ho ws a s ac cul ar an eur ys m of t he aort i c a r ch wi t h a s hort neck and a part i al l y t hro m bos ed l um en wi t h a cros s s e ct i onal di a m et er of 53 m m
Fi gu re 2.
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P eroperat i ve i m a ge of t he 3D-f ram i n g c oi l fi l l ed wi t h s everal det ach abl e coi l s .
Fi gu re 3.
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P os t operat i ve C T s hows com pl et e t hrom bos i s of t he aneur ys m .
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Fi gu re 4.
Angi o gr aph y at t he end of t he pro cedur e wi t h ful l cover a ge of t he s ac cul ar aneur ys m b y a t hor a ci c endopros t hes i s a nd endovas cul a r deb ranchi n g of t he l eft com m on carot i d art e r y b y chi m ne y-t e chn i que and endovas cul ar debr anchi n g of
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t he l eft s ubcl avi an a rt er y b y peri s cope t echni que.
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S0890-5096(15)00496-3
DOI:
10.1016/j.avsg.2015.03.062
Reference:
AVSG 2414
To appear in:
Annals of Vascular Surgery
Received Date: 3 January 2015 Revised Date:
15 March 2015
Accepted Date: 30 March 2015
Please cite this article as: Martens S, Maene L, Beelen R, Complete endovascular treatment of saccular aneurysm of the aortic arch by coiling and ch-EVAR, Annals of Vascular Surgery (2015), doi: 10.1016/ j.avsg.2015.03.062. 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
Co mp let e endova scular t reat me nt o f sac cular aneu r ys m o f the ao rtic a rch b y coiling and ch -E V AR
Corresponding Author: Dr. Sebastiaan Martens, MD
M AN U
SC
Corresponding Author's Institution: OLV Clinic Aalst Cardiovascular and thoracic surgery Moorselbaan 164 9300 Aalst Belgium
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S EBAS T IAAN M AR TENS - LIEVEN M AENE - R OE L BEE LEN
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First Author: Sebastiaan Martens, MD Department of Cardiovascular an Thoracic Surgery OLV Clinic Aalst Moorselbaan 164 9300 Aalst Belgium [email protected] Tel.: 0032 (0)53/72.45.99
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Order of Authors: Sebastiaan Martens, MD, Lieven Maene, MD, Roel Beelen, MD
ACCEPTED MANUSCRIPT ABS TR AC T S accul ar aneur ys m of t he aort i c a rch i s a condi t i on wi t h a hi gh as s o ci at ed m ort al i t y. Open s u rger y i s oft en com pl i cat ed wi t h poor out com e and hi gh pos t operat i ve m orbi di t y and m ort al i t y. In t hi s cas e repo rt
we des cri be an
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al t ernat i ve s t epwi s e endovas cul a r r epai r: coi l i ng of t he an eur ys m fol l owed b y coveri n g of t he os t i um of t he s accul ar aneur ys m b y ch-EV AR . In our opi ni on t hi s t echni que coul d be an al t ernat i v e for a ful l y cus t om i z ed branched o r
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fenes t rat ed endopro s t hes i s t o t reat t hes e ki nd of aneur ys m s .
ACCEPTED MANUSCRIPT IN TR ODUC T IO N A s accul a r aneu r ys m of t he aort i c ar ch i s a pos s i bl e l i fe t hreat eni n g condi t i o n. The y a re t radi t i on al l y t reat ed b y o pen s urger y.
S urge r y p erfo rm ed fo r
corre ct i on of an eur ys m s of t he aort i c arch i s o ft en co m pl i cat ed wi t h poor (1,2,3)
.
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out com es and a hi gh pos t operat i ve m orb i di t y and m ort al i t y
S i nce 1991 endovas cul ar t herap y has b een em er gi n g as an effect i ve and l es s i nvas i ve t reat m ent for aort i c aneu r ys m s .
M ore a nd m ore cas e report s can b e
found about t he us e of endopros t hes i s i n aort i c pat hol o g y wi t h di ffi cul t l andi ng The us e of branched gr aft s , fenes t rat ed gr aft s , chi m ne y gr aft s and
occl uder d evi ces i s m ore and m ore ac ce pt ed
(2)
.
SC
z ones .
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In t hi s r eport w e de s cri be a cas e of a s accul a r an eur ys m of t he aort i c arch t h at was s ucces s ful l y t r e at ed b y coi l i ng of t he l um en com bi ned wi t h a chi m ne y s t en t t o debran ch t e l eft c arot i d art er y and a s econd s nork el s t ent t o debran ch t he l eft
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s ubcl avi an art er y. To our knowl ed ge, t hi s i s t he fi rs t cas e publ i s hed.
ACCEPTED MANUSCRIPT C AS E R EP OR T W e report a cas e of a 72 - yea r ol d pat i ent wi t h an a cci den t al l y found s a ccul a r aneur ys m of t he aor t i c arch ( Fi g. 1). The m edi cal hi s t or y of our p at i ent was s i gni fi c ant for C OP D, AHT, l ung
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em bol i s m , pros t at e carci nom a wi t h rob ot i c res ect i on, end s t age ki dne y di s eas e wi t h hem odi al ys i s a nd s ucces s ful ki dne y t rans pl ant at i on i n 2007.
He had no com pl ai n t s and was com pl et e as ym pt om at i c of t h e aneur ys m . Ther e was a norm al ph ys i cal ex am i nat i on. In l aborat or y eval uat i on, whi t e bl ood cel l
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count and C -re act i v e prot ei n (C R P ) l evel were no rm al .
C om put ed t om ograp h y s can (C T-s c an) of t horax and abdo m en was per form ed Thi s C T-s c an s hows a s a ccul a r
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due t o an epi s ode o f fev er of unkno wn caus e.
aneur ys m of t he aor t i c arch wi t h a s hort neck and a part i al l y t h rom bos ed l um en wi t h a cros s s ect i on al di am et er o f 53 m m (Fi g.1).
The an eur ys m was l o cat ed
near t o t he os t i um of t he l eft s ubcl avi an art er y.
In fect i ous o ri gi n e o f t he aneur ys m was rul ed out b y m ul t i pl e bl oodcul t ures and
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P os i t ron em i s s i on Tom ograp h y s can (P ET-s can). Bec aus e of t h e m e di cal hi s t or y and t he as ym pt om at i c c ours e of our pat i en t , cons ervat i ve t r eat m ent was undert ak en i ni t i al l y.
How ever, t he an eur ys m
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enl ar ged on cons e cu t i ve C T-s can s o t reat m ent becam e m and at or y. B ene fi t s and ri s ks of t he di ffe ren t t reat m ent opt i ons were cons i der ed an d di s cus s ed wi t h our
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pat i ent .
Bec aus e o f t he m edi cal hi s t or y and t h e hi gh m orbi di t y and m ort al i t y of t h e ope n repai r
we
pref err ed
a
s t epwi s e
co m pl et e
endovas cul ar
appro ach
by
a
com bi nat i on of coi l em bol i z at i on and chi m ne y Thora ci c endovas cul a r Aort i c R epai r (ch-TE VAR ) .
H yb ri d s urgi c al debranchi n g pro ced ures m a y
di m i ni s h
s om e of t he bene fi t s of endov as cul a r s ur ge r y, es p eci al l y i n pat i ent s wi t h s eve re com orbi di t y. Bec aus e o f t he con t ras t l oad and t he durat i on of t he pro cedure, a s t epwi s e approach w as pr efe rred i n our pat i ent wi t h hi s t or y of a ki dne y t rans pl ant at i on and cardi ac fai l ur e. M oreover t he e ffi c ac y and dur abi l i t y o f each s t ep al on e i n aort i c s ac cul ar aneu r ys m s i s not cl ea r fo r t he m om ent .
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The fi rs t s t age i n ou r s t epwi s e approa ch was percut anous co i l i ng of t he s accul ar aneur ys m .
The pro cedure w as perfo rm ed under gene ral an es t hes i a, wi t h 5000
IU of hep ari n gi ve n s ys t em i cal l y. ri ght f em oral a rt er y.
A 6 Fren ch
s he at h w as i nt roduced i n t h e
W i t h t he us e of a S i m m ons 1 cat het er (Terumo Medical
Corporation, Somerset, New Jersey) t he a neur ys m was ac ce s s ed.
A P ro gre at
m i crocat het e r (T eru m o Medical Corporation, Somerset, New Jersey) was advan ced i n
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t he aneu r ys m al c avi t y. Fi rs t t o cr eat e a m at ri x , a 3D- fram i ng coi l 20m m x 50cm (Terum o Az ur Fr am i ng coi l , T erum o Medical Corporation, Somerset, New Jersey) was pl aced i n t h e an eu r ys m .
Aft e rwa rds t hi s m at ri x was f i l l ed
wi t h s eve ral
det achabl e coi l s (20m m x 30 cm , 15m m x 30cm , 15mm x 20cm ) (Terum o A ZUR
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P eri pheral H ydroC o i l Em bol iz at i on S ys t em , Terum o Medical Corporation, Somerset, New Jersey) . C ont rol angi o gr am peroper at i ve s hows com pl et e t hrom bos i s of t he The proce dure was unevent ful l and t he pat i ent was
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aneur ys m (Fi g. 2) ( Fi g. 3).
di s char ged f rom t he hos pi t al 2 da ys a ft e r t he oper at i on.
The s econd s t a ge, ch-TEVAR - repai r w as s chedul ed 2 we e ks l at er. Tr eat m ent obj ect i ve
w as
ful l
cover a ge
of
the
s ac cul ar
aneu r ys m
by
a
t hor aci c
endopros t hes i s and endovas cul a r deb ran chi ng of t h e l e ft co m m on carot i d art er y b y a chi m ne y-t echn i que and endovas cu l ar debran chi n g of t he l eft s ubcl avi an
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art er y b y a pe ri s cop e t echni que (Fi g. 4 ) .
B ecaus e of a w orki ng art eri ov enous
fi s t ul a i n t he l eft arm , revas cul ari s at i on of t he l eft s ubcl avi an art e r y was m andat or y.
M oreover rec ent evi dence has s hown an i ncreas e i n neurol o gi c
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m orbi di t y wi t hout revas cul a ri z at i on of t he l eft s ubcl avi an ar t er y. B y a s m al l cut -do w n i n t he bas e of t he neck a 8 F rench s h eat h w as i nt roduced ret ro grad e i n t he l eft com m on art er y and i t was deb r anched b y chi m ne y
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t echni que t owards t he as cendi n g ao rt a wi t h a Bent l e y- Inno m ed P eri pheral S t ent Graft S ys t em s t ent 8m m di am et er 57 m m l en gt h ( Bentley InnoMed, Hechingen, Germany).
Th e s ub cl avi an a rt er y was debranch ed wi t h a GOR E ® V IA BAHN ®
Endopros t hes i s of 10m m di am et er and 1 5 cm l engt h (Cook Medical, Bloomington, Ind) as a p eri s cop e gr af t t owards t he des c e ndi ng aort a. Thi s was done b y a 8 F r s heat h i n t he l eft gr oi n. W i t h al l gui de wi res i n pl a ce and bal l oons i nfl at ed i n t he chi m ne y and p eri s cope gr aft t he os t i um of t he s acc ul ar aneu r ys m w as covered wi t h a M e dt roni c Val i ant endopros t es i s of 36mm di am et er 150 mm l engt h (M edt roni c, Minneapolis, Minn) groi n.
i ns ert ed percut an e ous l e y b y t he ri ght
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Angi o gr aph y done i n t he end of t he pr ocedure s howed p at ent carot i d v es s el s ; pat ent l eft s ub cl avi an art er y an a t ot al ex cl us i on of t he s ac cul ar aneur ys m (Fi g. 4). The
pos t operat i ve
com pl i cat i on.
cours e
was
un event ful l ;
t here
were
no
neurol o gi c
Our pat i ent had a s hor t epi s ode of at ri al fi bri l l at i on but was
i n good cl i ni cal con di t i on t he hos pi t al .
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res t ored i nt o s i nus rh yt hm b y am i oda ron e. Fi ve da ys aft er t he operat i on he l eft
C ont rol C T-s can a ft er 6 and 12 m ont hs s hows no fl ow i n t he aneu r ys m al s ac, com pl et e t hrom bos i s of t he aneur ys m a l l um en and good pat enc y of bot h t h e
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chi m ne y and peri s co pe graft s t o t he s upr a-aort i c v es s el s .
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D IS C US S ION An art eri al aneu r ys m i s defi ned as a perm anent di l at a t i on b y 50% gre at er
fus i form t yp e, or t h e m ore r are s accul ar t ype Et hi ol ogy
of
s a cc ul ar
aneu r ys m s
is
(4)
.
vari ed,
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di am et er of t he nor m al ves s el . The y c an be cat e go ri z ed i nt o t he m ore com m on
i ncl udi n g
aort i c
i nfe ct i on,
s urger y
(5,6)
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degener at i on of a penet rat i n g at heros cl erot i c ul cer, t r aum a and previ ous aort i c .
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The com m on per cep t i on t hat t he nat ural hi s t or y of a s ac cul ar aneu r ys m i s m ore m al i gnant i s not pr oved and t he re al r i s k of rupt ure i n s a ccul ar aneu r ys m s i n unknown
(6)
. For a s accul a r an eur ys m o f t he ao rt i c ar ch op en s ur gi cal repai r i s
t oda y t he t reat m ent of choi ce, as s oci at e d wi t h hi gh m orbi di t y and m ort al i t y. In t he l as t 3 dec ades endovas cul a r m ana gem ent has be en i nc reas i n gl y be com e a n al t ernat i ve,
l es s i nvas i ve and eff ect i ve t reat m ent for a ort i c di s orders
(7)
.
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Howeve r for p at hol og y of t he ao rt i c a rch, conv ent i onal e ndovas cul ar s t ent i n g can be di ffi cul t bec aus e of t he di ffi cul t l andi ng z one and for pres ervi n g fl ow (2)
.
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i nt o t he s upra-aort i c ves s el s
S everal endov as cul ar t echni ques , i ncl u di ng coi l em bol i z at i on and endol um i nal s t ent gr aft s , have b een us ed s uc ces s ful l y.
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s m al l necked an eur ys m s .
C oi l s have bee n effe ct i ve us ed i n
Thi s t echni que c annot be pe rf orm ed i n fus i form
aneur ys m s , t he ane ur ys m m us t be s ac c ul ar, wi t h t he di am et er of t he s a c l ar ger t han t he ne ck t o e nabl e i nt ra- aneur ys m al coi l packi n g wi t hout ri s k of coi l di s pl acem ent
in
the
endovas cul a r opt i on
(7)
C om pl et e ex cl us i on of
art eri al
l um en .
S t ent -graft
ex cl us i on
is
anot her
. bl ood fl ow i n
t o t he aneur ys m i s es s ent i al .
Leak a ge
i nt o t he aneur ys m al s ac can r es ul t i n enl ar gem ent of t he aneur ys m al s ac and event ual l y rupt ure. In our pat i ent w e prefe rred a com bi ne d t echni que wi t h coi l em bol iz at i on and chi m ne y s t ent gr aft i ng be caus e of t h e l ocat i on of t he s ac c ul ar an eur ys m .
Th e
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neck of t he s a ccul a r aneur ys m was l oc at ed cl os e t o t he l e ft s ubcl avi an art e r y. The fi rs t s t ep of t he pro cedur e w as c oi l em bol i s at i on of t he aneur ys m . The s econd s t ep was pl acem ent of a t horaci c s t ent - gra ft , perfus i on of t he l eft s ubcl avi an art er y a nd t he l eft carot i d art er y was pres e r ved wi t hout s urgi c al b ypas s b y us i n g a c hi m ne y and s no rkel gr aft . Al t hough coi l i ng a nd chi m ne y s t ent graft i n g s epar at el y a re des cri b ed earl i e r ,
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t hei r com bi nat i on as a novel t reat m ent h as not been des cri be d before.
In s um m a r y, t hi s s t epwi s e proc edure i s a t echni c al l y f ea s i bl e, l es s i nvas i ve,
be
an
al t ern at i ve
for
ful l y
cus t o m i z ed
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durabl e and s a fe t r e at m ent for hi gh ri s k pat i ent s . The des c ri bed t echni que coul d branched
or
fenes t r at ed
aort i c
del i ver y i nt e rval .
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endopros t hes i s . Es peci al l y b ec aus e t ho s e gr aft s hav e a l ong produ ct i on and Durabi l i t y con cerns are s t i l l pres ent , l ong-t e rm fol l ow-up i s
ex cept i onal l y i m por t ant i n l i ght of t he i nt eract i ons of t he s t ent s , t he t horaci c endograft and t he a ort i c ar ch. At s ho rt -t erm fol l ow up our procedu re s eem s t o be eff ect i ve.
How e ver, l onger fol l ow up i s needed t o as s es s t he effi c ac y an d
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durabi l i t y.
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1.
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R EFER ENC ES M ul der EJ , Bockel H, M aas J . M orbi di t y and m o rt al i t y o f recons t ruct i ve s urger y o f noni nfec t ed fal s e aneur ys m s det ect ed l ong aft e r aort i c pros t het i c recons t ruct i on. A rch S urg 1998; 133: 45-9 .
Ohrl ander T., S ones s on B, Ivan cev K, R es ch T, Di as N, M al i na M .
SC
2.
The
C hi m ne y graft : A t echni que for pres e rv i ng or res cui i n g aor t i c branch ves s el s
3.
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i n s t ent gra ft s eal i n g z ones . J Endovas c Ther 2008; 15: 427- 32 Dake M D, M i l l er DC , S em ba C P , M it chel l R S , W al ker P J , Li ddel l R P . Trans l um i nal pl ace m ent of endovas cu l ar s t ent - gr aft s for t he t reat m ent o f des cendi n g
t hor aci c
aort i c
29; 331(26): 1729-34.
N
Engl
J
M ed.
1994
De c
J ohns t on KW , R ut herford R B, Ti l s on M D, S hah DM , Holl i er L, S t anl e y
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4.
aneur ys m s .
J C . S ugges t ed s t and ards fo r r eport i ng o n art e ri al an eur ys m s S ubcom m i t t ee on R eport i ng S t and ards for Art e ri al An eur ys m s , Ad Hoc C om m i t t ee on R eport i n g S t andards , S oci et y for Vas cul a r S urge r y and Nort h
Am eri can C hapt e r,
5.
EP
Int e rnat i onal S oci et y fo r C ardi ovas cul ar S urge r y. J Vas c S urg 1991; 13: 452-8. Kam pm ei er R .H. S accul ar an eur ys m of t he t horaci c ao rt a: a cl i ni cal s t ud y
6.
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of 633 cas es . Ann Int ern M ed. 1938; 12( 5): 624-651 Eri c K. S han g, M D ,a De rek P . N at han , M D,a W i l l i am W . Boonn, M D,b Iv an A. Lys -Dobr a di n,a R onal d M . Fai rm an, M D,c Edwar d Y. W oo, M D A m odern ex peri enc e wi t h s accul ar aort i c aneur ys m s J VAS C S urg 2013; 57: 84-8 7.
R akes h P . P at el , Athanas i os Kat s ar g yri s , Eri c L. G. Verho even, Donal d J . Adam , J ohn A. Har dm an Endovas cul ar aort i c aneu r ys m re pai r wi t h chi m ne y and s norkel gra ft s : i ndi cat i ons , t echni ques and res ul t s . C ardi oVas cul ar and Int e rvent i onal R adi ol og y De cem be r 201 3, Vol um e 36, Is s u e 6, pp 1443-1451
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Fi gu re 1.
P reoperat i ve C T s ho ws a s ac cul ar an eur ys m of t he aort i c a r ch wi t h a s hort neck and a part i al l y t hro m bos ed l um en wi t h a cros s s e ct i onal di a m et er of 53 m m
Fi gu re 2.
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P eroperat i ve i m a ge of t he 3D-f ram i n g c oi l fi l l ed wi t h s everal det ach abl e coi l s .
Fi gu re 3.
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P os t operat i ve C T s hows com pl et e t hrom bos i s of t he aneur ys m .
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Fi gu re 4.
Angi o gr aph y at t he end of t he pro cedur e wi t h ful l cover a ge of t he s ac cul ar aneur ys m b y a t hor a ci c endopros t hes i s a nd endovas cul a r deb ranchi n g of t he l eft com m on carot i d art e r y b y chi m ne y-t e chn i que and endovas cul ar debr anchi n g of
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t he l eft s ubcl avi an a rt er y b y peri s cope t echni que.
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