Case Report
Endovascular Stent for Iatrogenic Penetrating Injury of the Thoracic Aorta
Vascular and Endovascular Surgery 2014, Vol. 48(4) 333-336 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574413518617 ves.sagepub.com
Parsia A. Vagefi, MD1, Madhukar S. Patel, MD1, and Glenn M. LaMuraglia, MD1
Abstract Purpose: This is a report of the endovascular management of an iatrogenic descending thoracic aortic injury with long-term follow-up. Case Report: A 74-year-old medically complex female underwent the inadvertent percutaneous placement of a 6F sheath directly into the descending thoracic aorta during an attempted pericardiocentesis at an outside hospital. Upon transfer, the patient underwent endovascular placement of a thoracic stent graft to cover the entry site and recovered without incidence. The patient has remained free of complications for nearly 8 years of follow-up care. Conclusions: Endovascular stent graft utilization of the thoracic aorta has increased the treatment scope for the management of emergent and elective aortic pathology. This is particularly useful in clinical scenarios deemed too high an open surgical risk secondary to significant comorbidities. Keywords aortic injury, thoracic aortic stent graft, endovascular therapy
Introduction Since the introduction of stent graft treatment for abdominal aortic aneurysms, there has been technological advances to broaden its application to thoracic aortic pathologies. This powerful, minimally invasive technology, as applied in either the elective or emergent setting, has allowed for the management of patients whose medical comorbidities previously placed them at too high a risk for a conventional open surgical procedure.
Case Report A 74-year-old woman with a past medical history significant for atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, and ovarian cancer was admitted to an outside hospital with a 1-month history of fatigue and severe dyspnea. As imaging demonstrated a moderate to large pericardial effusion concerning for cardiac tamponade, the patient underwent percutaneous pericardiocentesis. The initial attempt was complicated by direct cannulation of the descending thoracic aorta with a 6F sheath that was left in place. Subsequently, a second attempt at pericardiocentesis was successful in draining a 700 cm3 pericardial fluid collection resulting in some clinical improvement. The patient was subsequently transferred to our institution for coordination of definitive management of the thoracic aortic sheath. The patient arrived hemodynamically stable and underwent a computed tomographic (CT) angiography prior to proceeding directly to the operating room for treatment. The CT angiogram of the chest and abdomen demonstrated a pericardial catheter
as well as a second catheter passing through the left lobe of the liver and into the descending thoracic aorta, with an entry point proximal to the celiac axis (Figure 1A-C). There was no evidence of a para-aortic hematoma, nor evidence of an esophageal or gastric injury. In the operating room, an upper gastrointestinal endoscopy verified no esophageal or gastric injury. As the patient was deemed too tenuous for a thoracotomy and direct repair, anatomic measurements were performed on the CT to determine the suitability for endovascular repair of the thoracic aorta. Under general anesthesia in the operating room with exposure of the left common femoral artery, the Seldinger technique was used to place a .035 Lunderquist wire (Cook Medical, Bloomington, IN) into the proximal descending thoracic aorta. A percutaneous 5F sheath was placed in the contralateral groin to access the thoracic aorta for angiography. After a thoracic angiogram, a .035 Rosen wire (Cook Medical, Bloomington, IN) was advanced through the 6-F sheath that was present in the patient’s thoracic aorta. Under fluoroscopic visualization, the thoracic aortic sheath was pulled back over the wire so that only 2 cm remained within the aortic lumen. Based on CT measurements, a 2-mm diameter 3.75-cm long Aneurx aortic cuff 1
Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Corresponding Author: Parsia A. Vagefi, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, White 544b, Boston, MA 02114, USA. Email: [email protected]
334
Vascular and Endovascular Surgery 48(4)
Figure 1. Preoperative computed tomography (CT) scan demonstrating passage of a 6F sheath through the left lobe of the liver (A) and subsequently through the descending thoracic aorta (B), with entry above the origin of the celiac axis (C).
Figure 2. Postoperative computed tomography (CT) scan demonstrating thoracic aortic stent graft placement in coronal (A), sagittal (B), and 3-dimensional reformatted images (C).
stent graft (Medtronic Inc, Santa Rosa, California) was positioned intraluminally at the level of the aortic penetration and partially deployed. Prior to complete deployment, the position of the aortic penetration was verified and the transaortic sheath was removed over the wire. A thoracic arteriogram was performed, demonstrating no evidence of a leak or contrast extravasation. The wire was subsequently retrieved over a straight catheter. The patient’s left femoral artery was repaired after sheath removal. The patient tolerated the procedure well without complication and was discharged home on postoperative day 14 after cardiac optimization. Over the ensuing nearly 8 years of follow-up, the thoracic stent graft demonstrated a stable appearance with no evidence of migration or endoleak (Figure 2A-C).
Discussion The evolution of endovascular stent graft placement developed from the desire to reduce the morbidity and mortality associated with open repairs of abdominal aortic aneurysms in high-risk surgical patients.1 Since the first report in 1994, the role of catheter-based intraluminal stent grafting in thoracic aortic disease continues to gain widespread application.2 The majority of studies for repairs of the descending thoracic aorta with the use of a stent graft have been for aneurysmal disease.3 However, there has been a growing body of evidence on the use of this technology in the setting of penetrating aortic trauma4,5 as well as iatrogenic injury to the thoracic aorta secondary to
Vagefi et al pedicle screws from spine surgery,6 puncture from an intra-aortic balloon pump,7 bronchial artery embolization,8 lung biopsy,9 and central line placement.10 We report here the first successful application of a thoracic aortic stent graft for an iatrogenic penetrating injury to the descending aorta during attempted pericardiocentesis. The patient’s multiple acute cardiopulmonary comorbidities made her a poor candidate for thoracotomy repair of her thoracic aorta. The procedure took approximately 80 minutes to complete, including the time to perform an upper gastrointestinal endoscopy to definitively rule out a transgastric or transesophageal passage of the sheath. In addition to the short-term technical success of the procedure to manage this thoracic aortic injury, this report solidifies the durability of this endovascular repair, with now nearly 8 years of documented follow-up. There have been numerous reports of the use of thoracic aortic stent grafts in both the elective and the emergency settings, demonstrating promising perioperative and short-term results with the use of this minimally invasive intervention when compared to open surgical repair.11,12 Subsequent follow-up has suggested that repair with descending thoracic aortic stent grafts, when compared with open surgery, has significantly lower perioperative mortality.13 In a recent single-center review of 100 patients with various acute catastrophes of the descending thoracic aorta requiring emergent repair, Naughton et al noted a significantly lower rate of perioperative mortality in patients treated with thoracic endovascular aortic repair compared to traditional open thoracic aortic repair (8% vs 29%, respectively).13 Furthermore, major respiratory complications were lower in the endovascular treated group (16% vs 48%, respectively), and there was a trend toward shorter mean length of hospital stay for the endovascular treated group (13.5 vs 16.3 days, respectively). However, it should be noted that reintervention rates and postoperative complications including myocardial infarction, acute renal failure, stroke, and paraplegia/paresis remained similar between both the approaches.13,14 The latter was also demonstrated by Stone et al who found the 48-month freedom from reintervention in their series of 198 patients of varying thoracic aortic pathology to be similar in the stent graft group versus the open surgery group (80% vs 78%, respectively).14 In the current report, it is important to note that the thoracic aortic stent graft utilized was not used according to its indication for use as approved by the Food and Drug Administration as it was approved for treatment of the abdominal aorta. Given the patient’s multiple cardiopulmonary comorbidities and her acute decompensation, the risk associated with undergoing an open surgical procedure was deemed too high and that a minimally invasive procedure would be in the best overall interest of the patient. As the device was available and appropriately sized for this patient, this procedure was a compassionate use of the device and very likely was life saving for this patient who was apprised of these issues for consent. Close follow-up has been reassuring as the follow-up CT images have demonstrated no complications.
335
Conclusion In summary, we present a medically complex patient with iatrogenic placement of a penetrating sheath into the descending thoracic aorta, managed with successful endovascular stent graft coverage of the entry site. Follow revealed a durable repair without complication for nearly 8 years. In the setting of traumatic vascular injury, placement of stent grafts provides an additional treatment modality that may benefit patients unsuitable for open surgical repair. However, controlled studies of the specific indications are necessary before widespread application. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004;351(16):1607-1618. 2. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med. 1994;331(26):1729-1734. 3. Svensson LG, Kouchoukos NT, Miller DC, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg. 2008; 85(1 suppl):S1-S41. 4. Baldwin ZK, Phillips LJ, Bullard MK, Schneider DB. Endovascular stent graft repair of a thoracic aortic gunshot injury. Ann Vasc Surg. 2008;22(5):692-696. 5. Fang TD, Peterson DA, Kirilcuk NN, Dicker RA, Spain DA, Brundage SI. Endovascular management of a gunshot wound to the thoracic aorta. J Trauma. 2006;60(1):204-208. 6. Loh SA, Maldonaldo TS, Rockman CB, et al. Endovascular solutions to arterial injury due to posterior spine surgery. J Vasc Surg. 2012;55(5):1477-1481. 7. Bautista-Hernandez V, Moya J, Martinell J, Polo ML, Fraile J. Successful stent-grafting for perforation of the thoracic aorta by an intraaortic balloon pump. Ann Thorac Surg. 2002;73(3): 956-958. 8. Bautista-Hernandez V, Gutierrez F, Roldan S, Capel A, Arcas R. Successful stent-grafting for iatrogenic aortic rupture and life-threatening hemoptysis. Minerva Chirurgica. 2007;62(5): 425-428. 9. Velu RB, Halak M, Muhlmann M, Baker S. Stent grafts for thoracic aortic pathology: single-center experience in Western Australia. Vascular. 2005;13(6):343-349. 10. Shrikhande GV, Khan SZ, Meltzer AJ, Gallagher K, Morrissey NJ. Endovascular management of type B aortic dissection after
336 attempted central venous catheterization. Ann Vasc Surg. 2011; 25(7):979 e13-e15. 11. Dake MD, Miller DC, Mitchell RS, Semba CP, Moore KA, Sakai T. The ‘‘first generation’’ of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta. J Thorac Cardiovasc Surg. 1998;116(5):689-703. 12. Doss M, Balzer J, Martens S, et al. Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience. Ann Thorac Surg. 2003;76(5):1465-1469.
Vascular and Endovascular Surgery 48(4) 13. Naughton PA, Park MS, Morasch MD, et al. Emergent repair of acute thoracic aortic catastrophes: a comparative analysis. Arch Surg. 2012;147(3):243-249. 14. Stone DH, Brewster DC, Kwolek CJ, et al. Stent-graft versus open-surgical repair of the thoracic aorta: mid-term results. J Vasc Surg. 2006;44(6):1188-1197. 15. Chuter TA. Fenestrated and branched stent-grafts for thoracoabdominal, pararenal and juxtarenal aortic aneurysm repair. Semin Vasc Surg. 2007;20(2):90-96.
Endovascular Stent for Iatrogenic Penetrating Injury of the Thoracic Aorta
Vascular and Endovascular Surgery 2014, Vol. 48(4) 333-336 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574413518617 ves.sagepub.com
Parsia A. Vagefi, MD1, Madhukar S. Patel, MD1, and Glenn M. LaMuraglia, MD1
Abstract Purpose: This is a report of the endovascular management of an iatrogenic descending thoracic aortic injury with long-term follow-up. Case Report: A 74-year-old medically complex female underwent the inadvertent percutaneous placement of a 6F sheath directly into the descending thoracic aorta during an attempted pericardiocentesis at an outside hospital. Upon transfer, the patient underwent endovascular placement of a thoracic stent graft to cover the entry site and recovered without incidence. The patient has remained free of complications for nearly 8 years of follow-up care. Conclusions: Endovascular stent graft utilization of the thoracic aorta has increased the treatment scope for the management of emergent and elective aortic pathology. This is particularly useful in clinical scenarios deemed too high an open surgical risk secondary to significant comorbidities. Keywords aortic injury, thoracic aortic stent graft, endovascular therapy
Introduction Since the introduction of stent graft treatment for abdominal aortic aneurysms, there has been technological advances to broaden its application to thoracic aortic pathologies. This powerful, minimally invasive technology, as applied in either the elective or emergent setting, has allowed for the management of patients whose medical comorbidities previously placed them at too high a risk for a conventional open surgical procedure.
Case Report A 74-year-old woman with a past medical history significant for atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, and ovarian cancer was admitted to an outside hospital with a 1-month history of fatigue and severe dyspnea. As imaging demonstrated a moderate to large pericardial effusion concerning for cardiac tamponade, the patient underwent percutaneous pericardiocentesis. The initial attempt was complicated by direct cannulation of the descending thoracic aorta with a 6F sheath that was left in place. Subsequently, a second attempt at pericardiocentesis was successful in draining a 700 cm3 pericardial fluid collection resulting in some clinical improvement. The patient was subsequently transferred to our institution for coordination of definitive management of the thoracic aortic sheath. The patient arrived hemodynamically stable and underwent a computed tomographic (CT) angiography prior to proceeding directly to the operating room for treatment. The CT angiogram of the chest and abdomen demonstrated a pericardial catheter
as well as a second catheter passing through the left lobe of the liver and into the descending thoracic aorta, with an entry point proximal to the celiac axis (Figure 1A-C). There was no evidence of a para-aortic hematoma, nor evidence of an esophageal or gastric injury. In the operating room, an upper gastrointestinal endoscopy verified no esophageal or gastric injury. As the patient was deemed too tenuous for a thoracotomy and direct repair, anatomic measurements were performed on the CT to determine the suitability for endovascular repair of the thoracic aorta. Under general anesthesia in the operating room with exposure of the left common femoral artery, the Seldinger technique was used to place a .035 Lunderquist wire (Cook Medical, Bloomington, IN) into the proximal descending thoracic aorta. A percutaneous 5F sheath was placed in the contralateral groin to access the thoracic aorta for angiography. After a thoracic angiogram, a .035 Rosen wire (Cook Medical, Bloomington, IN) was advanced through the 6-F sheath that was present in the patient’s thoracic aorta. Under fluoroscopic visualization, the thoracic aortic sheath was pulled back over the wire so that only 2 cm remained within the aortic lumen. Based on CT measurements, a 2-mm diameter 3.75-cm long Aneurx aortic cuff 1
Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Corresponding Author: Parsia A. Vagefi, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, White 544b, Boston, MA 02114, USA. Email: [email protected]
334
Vascular and Endovascular Surgery 48(4)
Figure 1. Preoperative computed tomography (CT) scan demonstrating passage of a 6F sheath through the left lobe of the liver (A) and subsequently through the descending thoracic aorta (B), with entry above the origin of the celiac axis (C).
Figure 2. Postoperative computed tomography (CT) scan demonstrating thoracic aortic stent graft placement in coronal (A), sagittal (B), and 3-dimensional reformatted images (C).
stent graft (Medtronic Inc, Santa Rosa, California) was positioned intraluminally at the level of the aortic penetration and partially deployed. Prior to complete deployment, the position of the aortic penetration was verified and the transaortic sheath was removed over the wire. A thoracic arteriogram was performed, demonstrating no evidence of a leak or contrast extravasation. The wire was subsequently retrieved over a straight catheter. The patient’s left femoral artery was repaired after sheath removal. The patient tolerated the procedure well without complication and was discharged home on postoperative day 14 after cardiac optimization. Over the ensuing nearly 8 years of follow-up, the thoracic stent graft demonstrated a stable appearance with no evidence of migration or endoleak (Figure 2A-C).
Discussion The evolution of endovascular stent graft placement developed from the desire to reduce the morbidity and mortality associated with open repairs of abdominal aortic aneurysms in high-risk surgical patients.1 Since the first report in 1994, the role of catheter-based intraluminal stent grafting in thoracic aortic disease continues to gain widespread application.2 The majority of studies for repairs of the descending thoracic aorta with the use of a stent graft have been for aneurysmal disease.3 However, there has been a growing body of evidence on the use of this technology in the setting of penetrating aortic trauma4,5 as well as iatrogenic injury to the thoracic aorta secondary to
Vagefi et al pedicle screws from spine surgery,6 puncture from an intra-aortic balloon pump,7 bronchial artery embolization,8 lung biopsy,9 and central line placement.10 We report here the first successful application of a thoracic aortic stent graft for an iatrogenic penetrating injury to the descending aorta during attempted pericardiocentesis. The patient’s multiple acute cardiopulmonary comorbidities made her a poor candidate for thoracotomy repair of her thoracic aorta. The procedure took approximately 80 minutes to complete, including the time to perform an upper gastrointestinal endoscopy to definitively rule out a transgastric or transesophageal passage of the sheath. In addition to the short-term technical success of the procedure to manage this thoracic aortic injury, this report solidifies the durability of this endovascular repair, with now nearly 8 years of documented follow-up. There have been numerous reports of the use of thoracic aortic stent grafts in both the elective and the emergency settings, demonstrating promising perioperative and short-term results with the use of this minimally invasive intervention when compared to open surgical repair.11,12 Subsequent follow-up has suggested that repair with descending thoracic aortic stent grafts, when compared with open surgery, has significantly lower perioperative mortality.13 In a recent single-center review of 100 patients with various acute catastrophes of the descending thoracic aorta requiring emergent repair, Naughton et al noted a significantly lower rate of perioperative mortality in patients treated with thoracic endovascular aortic repair compared to traditional open thoracic aortic repair (8% vs 29%, respectively).13 Furthermore, major respiratory complications were lower in the endovascular treated group (16% vs 48%, respectively), and there was a trend toward shorter mean length of hospital stay for the endovascular treated group (13.5 vs 16.3 days, respectively). However, it should be noted that reintervention rates and postoperative complications including myocardial infarction, acute renal failure, stroke, and paraplegia/paresis remained similar between both the approaches.13,14 The latter was also demonstrated by Stone et al who found the 48-month freedom from reintervention in their series of 198 patients of varying thoracic aortic pathology to be similar in the stent graft group versus the open surgery group (80% vs 78%, respectively).14 In the current report, it is important to note that the thoracic aortic stent graft utilized was not used according to its indication for use as approved by the Food and Drug Administration as it was approved for treatment of the abdominal aorta. Given the patient’s multiple cardiopulmonary comorbidities and her acute decompensation, the risk associated with undergoing an open surgical procedure was deemed too high and that a minimally invasive procedure would be in the best overall interest of the patient. As the device was available and appropriately sized for this patient, this procedure was a compassionate use of the device and very likely was life saving for this patient who was apprised of these issues for consent. Close follow-up has been reassuring as the follow-up CT images have demonstrated no complications.
335
Conclusion In summary, we present a medically complex patient with iatrogenic placement of a penetrating sheath into the descending thoracic aorta, managed with successful endovascular stent graft coverage of the entry site. Follow revealed a durable repair without complication for nearly 8 years. In the setting of traumatic vascular injury, placement of stent grafts provides an additional treatment modality that may benefit patients unsuitable for open surgical repair. However, controlled studies of the specific indications are necessary before widespread application. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004;351(16):1607-1618. 2. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med. 1994;331(26):1729-1734. 3. Svensson LG, Kouchoukos NT, Miller DC, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg. 2008; 85(1 suppl):S1-S41. 4. Baldwin ZK, Phillips LJ, Bullard MK, Schneider DB. Endovascular stent graft repair of a thoracic aortic gunshot injury. Ann Vasc Surg. 2008;22(5):692-696. 5. Fang TD, Peterson DA, Kirilcuk NN, Dicker RA, Spain DA, Brundage SI. Endovascular management of a gunshot wound to the thoracic aorta. J Trauma. 2006;60(1):204-208. 6. Loh SA, Maldonaldo TS, Rockman CB, et al. Endovascular solutions to arterial injury due to posterior spine surgery. J Vasc Surg. 2012;55(5):1477-1481. 7. Bautista-Hernandez V, Moya J, Martinell J, Polo ML, Fraile J. Successful stent-grafting for perforation of the thoracic aorta by an intraaortic balloon pump. Ann Thorac Surg. 2002;73(3): 956-958. 8. Bautista-Hernandez V, Gutierrez F, Roldan S, Capel A, Arcas R. Successful stent-grafting for iatrogenic aortic rupture and life-threatening hemoptysis. Minerva Chirurgica. 2007;62(5): 425-428. 9. Velu RB, Halak M, Muhlmann M, Baker S. Stent grafts for thoracic aortic pathology: single-center experience in Western Australia. Vascular. 2005;13(6):343-349. 10. Shrikhande GV, Khan SZ, Meltzer AJ, Gallagher K, Morrissey NJ. Endovascular management of type B aortic dissection after
336 attempted central venous catheterization. Ann Vasc Surg. 2011; 25(7):979 e13-e15. 11. Dake MD, Miller DC, Mitchell RS, Semba CP, Moore KA, Sakai T. The ‘‘first generation’’ of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta. J Thorac Cardiovasc Surg. 1998;116(5):689-703. 12. Doss M, Balzer J, Martens S, et al. Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience. Ann Thorac Surg. 2003;76(5):1465-1469.
Vascular and Endovascular Surgery 48(4) 13. Naughton PA, Park MS, Morasch MD, et al. Emergent repair of acute thoracic aortic catastrophes: a comparative analysis. Arch Surg. 2012;147(3):243-249. 14. Stone DH, Brewster DC, Kwolek CJ, et al. Stent-graft versus open-surgical repair of the thoracic aorta: mid-term results. J Vasc Surg. 2006;44(6):1188-1197. 15. Chuter TA. Fenestrated and branched stent-grafts for thoracoabdominal, pararenal and juxtarenal aortic aneurysm repair. Semin Vasc Surg. 2007;20(2):90-96.
