Cardiovasc Interv and Ther DOI 10.1007/s12928-014-0246-8
CASE REPORT
Covered stent implantation for anastomotic pseudoaneurysm of innominate artery post total aortic arch replacement Keisuke Fukuda • Yoshiaki Yokoi
Received: 13 November 2013 / Accepted: 19 January 2014 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2014
Abstract A 59-year-old man presented with back pain that lasted 2 h. Computed tomography revealed acute type A dissection. Emergent total aortic arch replacement was performed on the same day. In 2 weeks later, CT angiography (CTA) showed the aneurysm of his innominate artery. Endovascular repair using covered stent by transbrachial artery approach was successfully performed. CTA at 8 months showed that pseudoaneurysm was excluded. The patient had no symptoms and no other complications were seen. Percutaneous endovascular therapy can be applied for high-risk patient of suprathoracic open surgery. Keywords Covered stent Endovascular therapy Aneurysm Total aortic arch replacement
Introduction Percutaneous approach with covered stents or stent grafts for aneurysm in aortic branch vessels is a minimal invasive procedure [1–3]. Anastomotic pseudoaneurysm after thoracic aortic surgery is rare, but life-threatening complications. Therefore, early recognition and repair are required [4]. Open repairs, though, remain the gold standard in a supra-aortic region, but are associated with increased morbidity and mortality in redo thoracic surgery [5]. We presented a successful covered stent implantation via brachial artery for anastomotic pseudoaneurysm of innominate artery after total aortic arch replacement.
K. Fukuda (&) Y. Yokoi Department of Cardiology, Kishiwada Tokushukai Hospital, 4-27-1 Kamori, Kishiwada City, Osaka 596-8522, Japan e-mail: [email protected]
Case report A 59-year-old men presented to emergency room with severe back pain lasted for 2 h. His past history was hypertension and was not on medication. Emergent computed tomography (CT) found Stanford type A dissection. This dissection involved aortic arch. Emergent total aortic arch replacement using 3-branched vascular prosthesis whose branch sizes are 11, 9 and 9 mm, respectively (J graft SHIELD NEO; Japan Lifeline, Co.; Tokyo, Japan), was performed on the same day. In 2 weeks later, CT angiogram (CTA) was performed to evaluate the postoperative aortic arch. This CTA showed the new aneurysm located at innominate artery (Fig. 1). We could identify the entry site of flow into the aneurysm (Fig. 2a). For the further assessment, an arch aortography was performed via the right brachial artery which revealed aneurysm at innominate artery. Laboratory data showed no signs of infection. We measured exact target vessel size of innominate artery with CT (Fig. 2b). Although the diameter of branch of vascular prosthesis was 11 mm, the minimum diameter of the practical target vessel is 9 mm and the maximum is 11 mm by postoperative CT image. We estimated this aneurysm can be treated with endovascular therapy (EVT) by placing a covered stent, the size of which is 10 mm 9 40 mm. After discussion with the patient and surgeons, we decided to treat the aneurysm by EVT. Right brachial approach was taken in consideration to avoid the procedural manipulation in residual dissected vessel. A 5-Fr pigtail catheter was positioned in the ascending aortic through left radial artery for aortic arch angiography. Right brachial artery was cut down and 9-Fr sheath was placed. 5000 units of unfractionated heparins were administered intravenously. From the right brachial
123
K. Fukuda, Y. Yokoi
Fig. 1 3DCTA in 2 weeks later post-operation. An aneurysm was located in innominate artery (arrow)
artery, a 0.035-inc 1.5 mm J-shaped hydrophilic wire was advanced with the assistance of a 4-Fr multipurpose catheter (Goodman; Nagoya, Japan) to successfully cross the lesion. After crossing the lesion, guide wire was exchanged to 0.035-inc Amplatz stiff wire (Cook Medical; Bloomington, IN, USA) to place covered stent. The size of Covered stent was 10 9 40 mm (Fluency; BARD, Inc.; Murray Hill, NJ, USA). The length of the uncovered portion of the stent graft is approximately 2 mm at each end, not including the radiopaque markers. This stent was positioned at the entry of aneurysm and this position was confirmed by the angiography. Prior to this procedure we had measured the distance from the entry site of pseudoaneurysm to the proximal and distal end of the innominate artery with CTA. The origin of innominate artery in LAO view and the distal bifurcation in RAO view were confirmed by aortography. In consideration of these positional relationship and length of the stent, position adjustment of proximal edge of the covered stent was prioritized for the purpose of covering the entry of the aneurysm and preventing stent jail of the distal bifurcation of common carotid artery. Covered stent was placed at innominate artery (Fig. 3a). First post-dilatation was performed by 8 mm 9 40 mm balloon (Adomiral; Medtronic, Minneapolis, MN, USA) at 6 ATM (Fig. 3b). Angiogram post-stenting showed low leakage outside stent (Fig. 3c). As estimating that stent was not fully expanded, additional dilatation was carried out with 10 mm 9 40 mm balloon (Adomiral; Medtronic, Minneapolis, MN, USA) (Fig. 3d). This post-balloon dilatation sealed endoleak. Final angiogram showed no remarkable leakage. Post-procedure, CTA was taken on the 14th day. This CT shows residual aneurysm of proximal edge of the covered stent in innominate artery, but its size became smaller as compared with pre-procedure size (Fig. 4a). We found the aneurysm was getting smaller and could expect to be thrombosed. The patient was asymptomatic in clinical course after procedure. No distal ischemia and no neurological signs were found. CTA at 8 months, aneurysm could not be seen (Fig. 4b).
Discussion
Fig. 2 a Coronal section of enhanced CT. Arrow-head marks entry point of blood flow into the aneurysm sac. b Sagittal section of enhanced CT. The length and diameter of innominate artery were precisely measured. PA pseudoaneurysm, IA innominate artery, CA carotid artery, Ao aorta
123
Anastomotic pseudoaneurysms are rare, with catastrophic complications after thoracic aortic surgery. The incidence of pseudoaneurysms post-surgical repair of acute aortic dissection is 2–3 % [6, 7]. Pseudoaneurysms originated from innominate artery are considered as rare occurrence. Treatment of the aneurysm is indispensable to prevent serious sequelae involving rupture, compressive symptoms and cerebral embolism from thrombus in the aneurysm. In
Covered stent for anastomotic pseudoaneurysm
Fig. 3 a Covered stent was placed at innominate artery. b First postdilatation was performed by 8 9 40 mm balloon. c Residual blood flow was recognized outside of covered stent (arrow heads). d Additional dilatation was performed by 10 9 40 mm balloon
Fig. 4 a 3DCTA at 2 weeks later after covered stent implantation. The aneurysm became smaller size. b 3DCTA at 8 months showed the aneurysm had completely disappeared
the endovascular treatment era, several cases of successful treatment of aneurysms of innominate artery lesions caused by trauma, infections, vasculitis and iatrogenic injury have been reported [8–13]. To the best of our knowledge,
covered stent implantation for anastomotic pseudoaneurysm of innominate artery was not reported. Treatment of aneurysms of innominate artery lesions has conventionally been a surgical approach via a thoracotomy or median sternotomy with or without cardiopulmonary bypass. Open repair has proven to be successful [14]; however, exposure of the innominate artery is associated with increased morbidity and mortality. The minimally invasive endovascular approach may offer an alternative treatment option. Recently, there has been a move toward endovascular treatment of large vessel injury, including perforation, dissection, pseudoaneurysms and endoleaks. Pre-operative evaluation should proceed with detailed anatomic evaluation of all arch vessels. CTA and magnetic resonance angiography (MRA) are useful for detailed assessment of aneurysms and target vessels. Threedimensional (3D) reconstruction may provide additional useful information in planning the approach. Angiography is conventionally performed while it may carry a risk of complication of vascular incidence [3]. Either open or endovascular procedure may be successfully underwent with combination of these options. In this case, the patient suffered from type A dissection and underwent total arch replacement. Therefore, redoing open surgery for innominate artery carries high risks. After discussion with the patient and surgeons, we decided to perform endovascular treatment for his innominate artery pseudoaneurysm. We speculated the aneurysm arising from anastomotic site of the graft to residual dissected innominate artery. CTA image precisely revealed entry site into the aneurysm. Placement of covered stent without open surgery was regarded as safety and feasible modality to exclude the aneurysm. Brachial artery approach was preferred to femoral artery with consideration for a risk of vascular accident due to catheter manipulation within postoperative aortic arch, while femoral approach is superior in terms of procedural stability and control. Because of scar tissue from the previous surgical intervention, femoral approach had been avoided. Endovascular stent-graft placement may conventionally require high profile vascular access, though, in this case, we could perform the procedure with relatively low profile and minimally invasive brachial approach.
Conclusion This case demonstrated that covered stent implantation for the anastomotic pseudoaneurysm of innominate artery after total arch replacement is the attractive option. Long-term outcome and durability of covered stent placement are not elucidated. In the post-suprathoracic aortic surgery, however, endovascular treatment for the
123
K. Fukuda, Y. Yokoi
anastomotic aneurysm is minimal invasive and effective procedure after suprathoracic aortic surgery. Conflict of interest
None.
References 1. Scho¨nholz CJ, Uflacker R, De Gregorio MA, Parodi JC. Stentgraft treatment of trauma to the supra-aortic arteries. A review. J Cardiovasc Surg. 2007;48:537–49. 2. Veraldi GF, Furlan F, Tasselli S, Tomasi I, Firpo M. Endovascular repair of intrathoracic left subclavian artery aneurysm with stent grafts: report of a case and review of the literature. Chir Ital. 2005;57:355–9. 3. Chambers CM, Curci JA. Treatment of nonaortic aneurysms in the endograft era: aneurysms of the innominate and subclavian arteries. Semin Vasc Surg. 2005;18:184–90. 4. Bower TC, Pairolero PC, Hallett JW Jr, Toomey BJ, Gloviczki P, Cherry KJ Jr. Brachiocephalic aneurysm: the case for early recognition and repair. Ann Vasc Surg. 1991;5:125–32. 5. Carrel T, Pasic M, Jenni R, Tkebuchava T, Turina MI. Reoperations after operation on the thoracic aorta: etiology, surgical techniques, and prevention. Ann Thorac Surg. 1993;56:259–68. 6. Siminelakis S, Baikoussis NG, Arnaoutoglou EM, Papadopoulos G, Goudevenos J. Aortic false aneurysm at the distal anastomotic suture line after aortic arch replacement; a case report with review of the literature. Eur Rev Med Pharmacol Sci. 2012;16:835–8.
123
7. Strauch JT, Spielvogel D, Lansman SL, Lauten AL, Bodian C, Griepp RB. Long-term integrity of teflon felt-supported suture lines in aortic surgery. Ann Thorac Surg. 2005;79:796–800. 8. Axisa BM, Loftus IM, Fishwick G, Spyt T, Bell PR. Endovascular repair of an innominate artery false aneurysm following blunt trauma. J Endovasc Ther. 2000;7:245–50. 9. Puech-Lea˜o P, Orra HA. Endovascular repair of an innominate artery true aneurysm. J Endovasc Ther. 2001;8:429–32. 10. Ahmed I, Katsanos K, Ahmad F, Dourado R, Lyons O, Reidy J. Endovascular treatment of a brachiocephalic artery pseudoaneurysm secondary to biopsy at mediastinoscopy. J Cardiovasc Interv Radiol. 2009;32:792–5. 11. de Troia A, Tecchio T, Azzarone M, Biasi L, Piazza P, Franco Salcuni P. Endovascular treatment of an innominate artery iatrogenic pseudoaneurysm following subclavian vein catheterization. Vasc Endovascular Surg. 2011;45:78–82. 12. Angiletta D, Marinazzo D, Guido G, Fullone M, Pulli R, Regina G. Eight-year follow-up of endovascular repair of a brachiocephalic trunk aneurysm due to Takayasu’s arteritis. J Vasc Surg. 2012;56:504–7. 13. Ito T, Kurimoto Y, Kawaharada N, Koyanagi T, Hashiguchi H, Yamashita A, et al. Endovascular stent-grafting of anastomotic pseudoaneurysms following thoracic aortic surgery. Gen Thorac Cardiovasc Surg. 2009;57:528–33. 14. Kieffer E, Chiche L, Koskas F, Bahnini A. Aneurysms of the innominate artery: surgical treatment of 27 patients. J Vasc Surg. 2001;34:222–8.
CASE REPORT
Covered stent implantation for anastomotic pseudoaneurysm of innominate artery post total aortic arch replacement Keisuke Fukuda • Yoshiaki Yokoi
Received: 13 November 2013 / Accepted: 19 January 2014 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2014
Abstract A 59-year-old man presented with back pain that lasted 2 h. Computed tomography revealed acute type A dissection. Emergent total aortic arch replacement was performed on the same day. In 2 weeks later, CT angiography (CTA) showed the aneurysm of his innominate artery. Endovascular repair using covered stent by transbrachial artery approach was successfully performed. CTA at 8 months showed that pseudoaneurysm was excluded. The patient had no symptoms and no other complications were seen. Percutaneous endovascular therapy can be applied for high-risk patient of suprathoracic open surgery. Keywords Covered stent Endovascular therapy Aneurysm Total aortic arch replacement
Introduction Percutaneous approach with covered stents or stent grafts for aneurysm in aortic branch vessels is a minimal invasive procedure [1–3]. Anastomotic pseudoaneurysm after thoracic aortic surgery is rare, but life-threatening complications. Therefore, early recognition and repair are required [4]. Open repairs, though, remain the gold standard in a supra-aortic region, but are associated with increased morbidity and mortality in redo thoracic surgery [5]. We presented a successful covered stent implantation via brachial artery for anastomotic pseudoaneurysm of innominate artery after total aortic arch replacement.
K. Fukuda (&) Y. Yokoi Department of Cardiology, Kishiwada Tokushukai Hospital, 4-27-1 Kamori, Kishiwada City, Osaka 596-8522, Japan e-mail: [email protected]
Case report A 59-year-old men presented to emergency room with severe back pain lasted for 2 h. His past history was hypertension and was not on medication. Emergent computed tomography (CT) found Stanford type A dissection. This dissection involved aortic arch. Emergent total aortic arch replacement using 3-branched vascular prosthesis whose branch sizes are 11, 9 and 9 mm, respectively (J graft SHIELD NEO; Japan Lifeline, Co.; Tokyo, Japan), was performed on the same day. In 2 weeks later, CT angiogram (CTA) was performed to evaluate the postoperative aortic arch. This CTA showed the new aneurysm located at innominate artery (Fig. 1). We could identify the entry site of flow into the aneurysm (Fig. 2a). For the further assessment, an arch aortography was performed via the right brachial artery which revealed aneurysm at innominate artery. Laboratory data showed no signs of infection. We measured exact target vessel size of innominate artery with CT (Fig. 2b). Although the diameter of branch of vascular prosthesis was 11 mm, the minimum diameter of the practical target vessel is 9 mm and the maximum is 11 mm by postoperative CT image. We estimated this aneurysm can be treated with endovascular therapy (EVT) by placing a covered stent, the size of which is 10 mm 9 40 mm. After discussion with the patient and surgeons, we decided to treat the aneurysm by EVT. Right brachial approach was taken in consideration to avoid the procedural manipulation in residual dissected vessel. A 5-Fr pigtail catheter was positioned in the ascending aortic through left radial artery for aortic arch angiography. Right brachial artery was cut down and 9-Fr sheath was placed. 5000 units of unfractionated heparins were administered intravenously. From the right brachial
123
K. Fukuda, Y. Yokoi
Fig. 1 3DCTA in 2 weeks later post-operation. An aneurysm was located in innominate artery (arrow)
artery, a 0.035-inc 1.5 mm J-shaped hydrophilic wire was advanced with the assistance of a 4-Fr multipurpose catheter (Goodman; Nagoya, Japan) to successfully cross the lesion. After crossing the lesion, guide wire was exchanged to 0.035-inc Amplatz stiff wire (Cook Medical; Bloomington, IN, USA) to place covered stent. The size of Covered stent was 10 9 40 mm (Fluency; BARD, Inc.; Murray Hill, NJ, USA). The length of the uncovered portion of the stent graft is approximately 2 mm at each end, not including the radiopaque markers. This stent was positioned at the entry of aneurysm and this position was confirmed by the angiography. Prior to this procedure we had measured the distance from the entry site of pseudoaneurysm to the proximal and distal end of the innominate artery with CTA. The origin of innominate artery in LAO view and the distal bifurcation in RAO view were confirmed by aortography. In consideration of these positional relationship and length of the stent, position adjustment of proximal edge of the covered stent was prioritized for the purpose of covering the entry of the aneurysm and preventing stent jail of the distal bifurcation of common carotid artery. Covered stent was placed at innominate artery (Fig. 3a). First post-dilatation was performed by 8 mm 9 40 mm balloon (Adomiral; Medtronic, Minneapolis, MN, USA) at 6 ATM (Fig. 3b). Angiogram post-stenting showed low leakage outside stent (Fig. 3c). As estimating that stent was not fully expanded, additional dilatation was carried out with 10 mm 9 40 mm balloon (Adomiral; Medtronic, Minneapolis, MN, USA) (Fig. 3d). This post-balloon dilatation sealed endoleak. Final angiogram showed no remarkable leakage. Post-procedure, CTA was taken on the 14th day. This CT shows residual aneurysm of proximal edge of the covered stent in innominate artery, but its size became smaller as compared with pre-procedure size (Fig. 4a). We found the aneurysm was getting smaller and could expect to be thrombosed. The patient was asymptomatic in clinical course after procedure. No distal ischemia and no neurological signs were found. CTA at 8 months, aneurysm could not be seen (Fig. 4b).
Discussion
Fig. 2 a Coronal section of enhanced CT. Arrow-head marks entry point of blood flow into the aneurysm sac. b Sagittal section of enhanced CT. The length and diameter of innominate artery were precisely measured. PA pseudoaneurysm, IA innominate artery, CA carotid artery, Ao aorta
123
Anastomotic pseudoaneurysms are rare, with catastrophic complications after thoracic aortic surgery. The incidence of pseudoaneurysms post-surgical repair of acute aortic dissection is 2–3 % [6, 7]. Pseudoaneurysms originated from innominate artery are considered as rare occurrence. Treatment of the aneurysm is indispensable to prevent serious sequelae involving rupture, compressive symptoms and cerebral embolism from thrombus in the aneurysm. In
Covered stent for anastomotic pseudoaneurysm
Fig. 3 a Covered stent was placed at innominate artery. b First postdilatation was performed by 8 9 40 mm balloon. c Residual blood flow was recognized outside of covered stent (arrow heads). d Additional dilatation was performed by 10 9 40 mm balloon
Fig. 4 a 3DCTA at 2 weeks later after covered stent implantation. The aneurysm became smaller size. b 3DCTA at 8 months showed the aneurysm had completely disappeared
the endovascular treatment era, several cases of successful treatment of aneurysms of innominate artery lesions caused by trauma, infections, vasculitis and iatrogenic injury have been reported [8–13]. To the best of our knowledge,
covered stent implantation for anastomotic pseudoaneurysm of innominate artery was not reported. Treatment of aneurysms of innominate artery lesions has conventionally been a surgical approach via a thoracotomy or median sternotomy with or without cardiopulmonary bypass. Open repair has proven to be successful [14]; however, exposure of the innominate artery is associated with increased morbidity and mortality. The minimally invasive endovascular approach may offer an alternative treatment option. Recently, there has been a move toward endovascular treatment of large vessel injury, including perforation, dissection, pseudoaneurysms and endoleaks. Pre-operative evaluation should proceed with detailed anatomic evaluation of all arch vessels. CTA and magnetic resonance angiography (MRA) are useful for detailed assessment of aneurysms and target vessels. Threedimensional (3D) reconstruction may provide additional useful information in planning the approach. Angiography is conventionally performed while it may carry a risk of complication of vascular incidence [3]. Either open or endovascular procedure may be successfully underwent with combination of these options. In this case, the patient suffered from type A dissection and underwent total arch replacement. Therefore, redoing open surgery for innominate artery carries high risks. After discussion with the patient and surgeons, we decided to perform endovascular treatment for his innominate artery pseudoaneurysm. We speculated the aneurysm arising from anastomotic site of the graft to residual dissected innominate artery. CTA image precisely revealed entry site into the aneurysm. Placement of covered stent without open surgery was regarded as safety and feasible modality to exclude the aneurysm. Brachial artery approach was preferred to femoral artery with consideration for a risk of vascular accident due to catheter manipulation within postoperative aortic arch, while femoral approach is superior in terms of procedural stability and control. Because of scar tissue from the previous surgical intervention, femoral approach had been avoided. Endovascular stent-graft placement may conventionally require high profile vascular access, though, in this case, we could perform the procedure with relatively low profile and minimally invasive brachial approach.
Conclusion This case demonstrated that covered stent implantation for the anastomotic pseudoaneurysm of innominate artery after total arch replacement is the attractive option. Long-term outcome and durability of covered stent placement are not elucidated. In the post-suprathoracic aortic surgery, however, endovascular treatment for the
123
K. Fukuda, Y. Yokoi
anastomotic aneurysm is minimal invasive and effective procedure after suprathoracic aortic surgery. Conflict of interest
None.
References 1. Scho¨nholz CJ, Uflacker R, De Gregorio MA, Parodi JC. Stentgraft treatment of trauma to the supra-aortic arteries. A review. J Cardiovasc Surg. 2007;48:537–49. 2. Veraldi GF, Furlan F, Tasselli S, Tomasi I, Firpo M. Endovascular repair of intrathoracic left subclavian artery aneurysm with stent grafts: report of a case and review of the literature. Chir Ital. 2005;57:355–9. 3. Chambers CM, Curci JA. Treatment of nonaortic aneurysms in the endograft era: aneurysms of the innominate and subclavian arteries. Semin Vasc Surg. 2005;18:184–90. 4. Bower TC, Pairolero PC, Hallett JW Jr, Toomey BJ, Gloviczki P, Cherry KJ Jr. Brachiocephalic aneurysm: the case for early recognition and repair. Ann Vasc Surg. 1991;5:125–32. 5. Carrel T, Pasic M, Jenni R, Tkebuchava T, Turina MI. Reoperations after operation on the thoracic aorta: etiology, surgical techniques, and prevention. Ann Thorac Surg. 1993;56:259–68. 6. Siminelakis S, Baikoussis NG, Arnaoutoglou EM, Papadopoulos G, Goudevenos J. Aortic false aneurysm at the distal anastomotic suture line after aortic arch replacement; a case report with review of the literature. Eur Rev Med Pharmacol Sci. 2012;16:835–8.
123
7. Strauch JT, Spielvogel D, Lansman SL, Lauten AL, Bodian C, Griepp RB. Long-term integrity of teflon felt-supported suture lines in aortic surgery. Ann Thorac Surg. 2005;79:796–800. 8. Axisa BM, Loftus IM, Fishwick G, Spyt T, Bell PR. Endovascular repair of an innominate artery false aneurysm following blunt trauma. J Endovasc Ther. 2000;7:245–50. 9. Puech-Lea˜o P, Orra HA. Endovascular repair of an innominate artery true aneurysm. J Endovasc Ther. 2001;8:429–32. 10. Ahmed I, Katsanos K, Ahmad F, Dourado R, Lyons O, Reidy J. Endovascular treatment of a brachiocephalic artery pseudoaneurysm secondary to biopsy at mediastinoscopy. J Cardiovasc Interv Radiol. 2009;32:792–5. 11. de Troia A, Tecchio T, Azzarone M, Biasi L, Piazza P, Franco Salcuni P. Endovascular treatment of an innominate artery iatrogenic pseudoaneurysm following subclavian vein catheterization. Vasc Endovascular Surg. 2011;45:78–82. 12. Angiletta D, Marinazzo D, Guido G, Fullone M, Pulli R, Regina G. Eight-year follow-up of endovascular repair of a brachiocephalic trunk aneurysm due to Takayasu’s arteritis. J Vasc Surg. 2012;56:504–7. 13. Ito T, Kurimoto Y, Kawaharada N, Koyanagi T, Hashiguchi H, Yamashita A, et al. Endovascular stent-grafting of anastomotic pseudoaneurysms following thoracic aortic surgery. Gen Thorac Cardiovasc Surg. 2009;57:528–33. 14. Kieffer E, Chiche L, Koskas F, Bahnini A. Aneurysms of the innominate artery: surgical treatment of 27 patients. J Vasc Surg. 2001;34:222–8.
