Endovascular Treatment of an Acutely Thrombosed Abdominal Aortic Aneurysm Jayandiran Pillai, Radha Jayakrishnan, Ceyhan Yazicioglu, Taalib Monareng, and Martin G. Veller, Johannesburg, South Africa
Background: Acute thrombosis of an infrarenal abdominal aortic aneurysm may be a lifethreatening condition. Report: We describe a case of acute thrombosis of a 3.5-cm abdominal aortic aneurysm resulting in threatened lower limbs, in a high-risk surgical patient. Emergency stent-graft placement was undertaken using Fluency endoprostheses. The patient remains well at 1-year follow-up. Conclusion: High-risk surgical patients with acutely thrombosed abdominal aortic aneurysms may not be candidates for open surgery. Use of peripheral stent grafts in emergency situation has not been reported in such patients.
Acute thrombosis of infrarenal abdominal aortic aneurysm (AAA) with severe lower limb ischemia is a surgical emergency that is associated with a high mortality rate. We report a case of acute thrombosis of the infrarenal abdominal aorta in a high-risk patient presenting with acute ischemia of both lower limbs treated endovascularly.
CASE REPORT A 75-year-old female presented with sudden paralysis of both lower limbs and backache. Symptoms were present for 8 hr. Risk factors for atherosclerosis included previous smoking, hypertension, and dyslipidemia. The associated comorbidities were atrial fibrillation and a previous myocardial infarct with prior coronary artery stent placement. On examination, the patient was restless, dyspnoeic, and agitated. Bilateral femoral pulses were absent and she had lost motor function and sensation
Division of Vascular Surgery, Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa. Correspondence to: Ceyhan Yazicioglu, BSc, BHScHon, 33 Craighall Road Victory Park, Johannesburg, South Africa; E-mail: c_yazicioglu@ yahoo.com Ann Vasc Surg 2015; 29: 1455.e13–1455.e15 http://dx.doi.org/10.1016/j.avsg.2015.05.021 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: November 11, 2014; manuscript accepted: May 27, 2015; published online: July 10, 2015.
in her lower limbs. Emergency contrast-enhanced computed tomography (CT) angiography revealed an occluded 3.5-cm diameter infrarenal aneurysm. A segment of the distal abdominal aorta and both iliac arteries were patent. Under local anesthesia, the brachial artery was exposed in the antecubital fossa. A 5F 90-cm sheath (OptiMed, Eddlingen, Germany) was inserted into the brachial artery and navigated to an infrarenal position. Arteriography confirmed a thrombosed 3.5-cm infrarenal aortic aneurysm. The infrarenal neck was irregular and 2-cm long. There was a patent 1.5-cm segment at the aortic bifurcation. The diameter of the neck tapered infrarenally from 13 mm to 10 mm. The width at the aortic bifurcation measured 12 mm (Fig. 1). A 125-cm Headhunter catheter (Cook, Bloomington. IN) together with a 0.03500 hydrophilic wire (Terumo Medical Corporation, Tokyo, Japan) was passed from the infrarenal segment through the thrombosed aneurysm into the right iliac artery. The hydrophilic wire was exchanged for a stiff Lunderquist wire (Cook). Anatomical landmarks to define the proximal landing zone (infrarenal aorta) and the distal landing zone (patent bifurcation segment) were documented before exchanging the 5F 90-cm sheath for a 9F 11-cm sheath (Cook). Two overlapping Fluency stent grafts were inserted from the brachial artery over the stiff Lunderquist wire. The distal stent graft (10e6 mm) was placed first to land in the patent distal aortic segment. The second stent graft (10e4 mm) overlapped the first by 2 cm and was placed in the infrarenal neck. Blood flow was re-established between the patent infrarenal and aortic bifurcation segment (and both iliac arteries) (Fig. 2). The
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Fig. 1. Initial arteriogram revealing the thrombosed aortic aneurysm. brachial artery was repaired with 6.0 Prolene sutures. At completion of the procedure, femoral pulses returned and the neurologic deficit improved over the next 2 hr. The patient was discharged in 48 hr on clopidogrel 75 mg daily and aspirin 75 mg daily. The patient remains asymptomatic at 1-year follow-up.
DISCUSSION This case demonstrates the use of peripheral stent grafts to treat a thrombosed infrarenal aortic aneurysm. The entire procedure was performed under local anesthesia using the left brachial artery for access. Approximately 50 cases of thrombosed infrarenal AAAs have been reported. The first case was reported by Schumacker in 1959.1 The current literature describes open surgical repair as the standard of care, either endoaneurysmorrhaphy or ligation with extra-anatomical bypass.1e7 Mortality of open surgical repair is reported to be in excess of 50%.3,4 In an emergency situation, one needs to distinguish between a thrombosed aortic aneurysm and a ‘‘saddle embolus’’ involving the aortic bifurcation. A high index of suspicion is necessary. A CT scan of the abdomen confirms the diagnosis and aids in endovascular planning. Use of peripheral stent grafts in the treatment of thrombosed aneurysm is particularly beneficial as
Annals of Vascular Surgery
Fig. 2. Fluency stent grafts placed in aneurysm.
stent graft - wall apposition in the infra-renal neck is not necessary to re-establish blood flow. In this way a smaller diameter peripheral stent graft maybe inserted as a ‘‘telescope’’ into a larger diameter inrarenal neck. The patient that we have described presented with severe comorbidities and severe ischemic symptoms which included neurologic deficit. The aim of the treatment was to restore circulation in the easiest possible way. The patient was assessed as high risk for open surgical repair. Kumar et al. used AneuRx stent graft (Medtronic Vascular, Santa Rose, CA) to treat a similar case. This involved exposure of both femoral arteries, brachial artery, and included the use of occlusion balloon to avoid thromboembolic complications.8 In the case described above, the key to success was the prompt diagnosis, the use of local anesthesia, and the presence of a patent aortic bifurcation segment to land the stent graft distally (Fig. 2). The use of small diameter stent grafts which are 9F sheath compatible may decrease the risk of thromboemboli. In our experience, an 8- to 10F sheath may be inserted into the brachial artery following a brachial cutdown. This allowed us to place 10-mm diameter stent grafts through the thrombosed aneurysm using only the brachial access. The procedure was completed in 45 min with rapid improvement in
Vol. 29, No. 7, October 2015
lower limb perfusion. However, long-term outcomes of such a strategy need further investigation. REFERENCES 1. Schumacker HB. Surgical treatment of aortic aneurysms. Postgrad Med 1959;25:535e48. 2. Sincos IR, da Silva ES, Ragazzo L, et al. Chronic thrombosed abdominal aortic aneurysms: a report on three consecutive cases and literature review. Clinics 2009;64:1227e30. 3. Suleman AS, Raffetto J, Seidman CS, et al. Acute thrombosis of abdominal aortic aneurysms: report of two cases and review of the literature. Vasc Endovascular Surg 2003;37:71e5.
Case reports 1455.e15
4. Bogie R, Willigendael EM, de Booij M, et al. Acute thrombosis of an abdominal aortic aneurysm: a short report. Eur J Vasc Endovasc Surg 2008;35:590e2. 5. Ricotta JJ, Kirshner R. Case report: late rupture of a thrombosed abdominal aortic aneurysm. Surgery 1984;95: 753e5. 6. Cervantes J, Martinez R, Perez-Garcia D. Acute thrombosis of abdominal aortic aneurysm, an uncommon entity. J Cardiovasc Surg 1985;26:598e601. 7. Hirose H, Takagi M, Hashiyada H, et al. Acute occlusion of an abdominal aortic aneurysm: case report and review of the literature. Angiology 2000;51:515e23. 8. Kumar V. Endovascular treatment of an acutely thrombosed AAA. J Endovasc Ther 2005;12:70e3.
Background: Acute thrombosis of an infrarenal abdominal aortic aneurysm may be a lifethreatening condition. Report: We describe a case of acute thrombosis of a 3.5-cm abdominal aortic aneurysm resulting in threatened lower limbs, in a high-risk surgical patient. Emergency stent-graft placement was undertaken using Fluency endoprostheses. The patient remains well at 1-year follow-up. Conclusion: High-risk surgical patients with acutely thrombosed abdominal aortic aneurysms may not be candidates for open surgery. Use of peripheral stent grafts in emergency situation has not been reported in such patients.
Acute thrombosis of infrarenal abdominal aortic aneurysm (AAA) with severe lower limb ischemia is a surgical emergency that is associated with a high mortality rate. We report a case of acute thrombosis of the infrarenal abdominal aorta in a high-risk patient presenting with acute ischemia of both lower limbs treated endovascularly.
CASE REPORT A 75-year-old female presented with sudden paralysis of both lower limbs and backache. Symptoms were present for 8 hr. Risk factors for atherosclerosis included previous smoking, hypertension, and dyslipidemia. The associated comorbidities were atrial fibrillation and a previous myocardial infarct with prior coronary artery stent placement. On examination, the patient was restless, dyspnoeic, and agitated. Bilateral femoral pulses were absent and she had lost motor function and sensation
Division of Vascular Surgery, Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa. Correspondence to: Ceyhan Yazicioglu, BSc, BHScHon, 33 Craighall Road Victory Park, Johannesburg, South Africa; E-mail: c_yazicioglu@ yahoo.com Ann Vasc Surg 2015; 29: 1455.e13–1455.e15 http://dx.doi.org/10.1016/j.avsg.2015.05.021 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: November 11, 2014; manuscript accepted: May 27, 2015; published online: July 10, 2015.
in her lower limbs. Emergency contrast-enhanced computed tomography (CT) angiography revealed an occluded 3.5-cm diameter infrarenal aneurysm. A segment of the distal abdominal aorta and both iliac arteries were patent. Under local anesthesia, the brachial artery was exposed in the antecubital fossa. A 5F 90-cm sheath (OptiMed, Eddlingen, Germany) was inserted into the brachial artery and navigated to an infrarenal position. Arteriography confirmed a thrombosed 3.5-cm infrarenal aortic aneurysm. The infrarenal neck was irregular and 2-cm long. There was a patent 1.5-cm segment at the aortic bifurcation. The diameter of the neck tapered infrarenally from 13 mm to 10 mm. The width at the aortic bifurcation measured 12 mm (Fig. 1). A 125-cm Headhunter catheter (Cook, Bloomington. IN) together with a 0.03500 hydrophilic wire (Terumo Medical Corporation, Tokyo, Japan) was passed from the infrarenal segment through the thrombosed aneurysm into the right iliac artery. The hydrophilic wire was exchanged for a stiff Lunderquist wire (Cook). Anatomical landmarks to define the proximal landing zone (infrarenal aorta) and the distal landing zone (patent bifurcation segment) were documented before exchanging the 5F 90-cm sheath for a 9F 11-cm sheath (Cook). Two overlapping Fluency stent grafts were inserted from the brachial artery over the stiff Lunderquist wire. The distal stent graft (10e6 mm) was placed first to land in the patent distal aortic segment. The second stent graft (10e4 mm) overlapped the first by 2 cm and was placed in the infrarenal neck. Blood flow was re-established between the patent infrarenal and aortic bifurcation segment (and both iliac arteries) (Fig. 2). The
1455.e13
1455.e14 Case reports
Fig. 1. Initial arteriogram revealing the thrombosed aortic aneurysm. brachial artery was repaired with 6.0 Prolene sutures. At completion of the procedure, femoral pulses returned and the neurologic deficit improved over the next 2 hr. The patient was discharged in 48 hr on clopidogrel 75 mg daily and aspirin 75 mg daily. The patient remains asymptomatic at 1-year follow-up.
DISCUSSION This case demonstrates the use of peripheral stent grafts to treat a thrombosed infrarenal aortic aneurysm. The entire procedure was performed under local anesthesia using the left brachial artery for access. Approximately 50 cases of thrombosed infrarenal AAAs have been reported. The first case was reported by Schumacker in 1959.1 The current literature describes open surgical repair as the standard of care, either endoaneurysmorrhaphy or ligation with extra-anatomical bypass.1e7 Mortality of open surgical repair is reported to be in excess of 50%.3,4 In an emergency situation, one needs to distinguish between a thrombosed aortic aneurysm and a ‘‘saddle embolus’’ involving the aortic bifurcation. A high index of suspicion is necessary. A CT scan of the abdomen confirms the diagnosis and aids in endovascular planning. Use of peripheral stent grafts in the treatment of thrombosed aneurysm is particularly beneficial as
Annals of Vascular Surgery
Fig. 2. Fluency stent grafts placed in aneurysm.
stent graft - wall apposition in the infra-renal neck is not necessary to re-establish blood flow. In this way a smaller diameter peripheral stent graft maybe inserted as a ‘‘telescope’’ into a larger diameter inrarenal neck. The patient that we have described presented with severe comorbidities and severe ischemic symptoms which included neurologic deficit. The aim of the treatment was to restore circulation in the easiest possible way. The patient was assessed as high risk for open surgical repair. Kumar et al. used AneuRx stent graft (Medtronic Vascular, Santa Rose, CA) to treat a similar case. This involved exposure of both femoral arteries, brachial artery, and included the use of occlusion balloon to avoid thromboembolic complications.8 In the case described above, the key to success was the prompt diagnosis, the use of local anesthesia, and the presence of a patent aortic bifurcation segment to land the stent graft distally (Fig. 2). The use of small diameter stent grafts which are 9F sheath compatible may decrease the risk of thromboemboli. In our experience, an 8- to 10F sheath may be inserted into the brachial artery following a brachial cutdown. This allowed us to place 10-mm diameter stent grafts through the thrombosed aneurysm using only the brachial access. The procedure was completed in 45 min with rapid improvement in
Vol. 29, No. 7, October 2015
lower limb perfusion. However, long-term outcomes of such a strategy need further investigation. REFERENCES 1. Schumacker HB. Surgical treatment of aortic aneurysms. Postgrad Med 1959;25:535e48. 2. Sincos IR, da Silva ES, Ragazzo L, et al. Chronic thrombosed abdominal aortic aneurysms: a report on three consecutive cases and literature review. Clinics 2009;64:1227e30. 3. Suleman AS, Raffetto J, Seidman CS, et al. Acute thrombosis of abdominal aortic aneurysms: report of two cases and review of the literature. Vasc Endovascular Surg 2003;37:71e5.
Case reports 1455.e15
4. Bogie R, Willigendael EM, de Booij M, et al. Acute thrombosis of an abdominal aortic aneurysm: a short report. Eur J Vasc Endovasc Surg 2008;35:590e2. 5. Ricotta JJ, Kirshner R. Case report: late rupture of a thrombosed abdominal aortic aneurysm. Surgery 1984;95: 753e5. 6. Cervantes J, Martinez R, Perez-Garcia D. Acute thrombosis of abdominal aortic aneurysm, an uncommon entity. J Cardiovasc Surg 1985;26:598e601. 7. Hirose H, Takagi M, Hashiyada H, et al. Acute occlusion of an abdominal aortic aneurysm: case report and review of the literature. Angiology 2000;51:515e23. 8. Kumar V. Endovascular treatment of an acutely thrombosed AAA. J Endovasc Ther 2005;12:70e3.
