CE: Namrta; JCM-D13-00580; Total nos of Pages: 4;
JCM-D13-00580
Perspective article
Preserving the left subclavian artery patency in challenging proximal neck during thoracic endovascular aortic repair Fabrizio Settepani, Giuseppe Maria Raffa, Pietro Giorgio Malvindi, Giuseppe Tarelli, Giorgio Brambilla and Vittorio Pedicini Coverage of the left subclavian artery in thoracic endovascular aortic repair is still a controversial procedure. We report a case of 30-year-old patient with a chronic rupture of the aortic isthmus and short proximal lending zone (10 mm) treated by thoracic endovascular aortic repair using a balloon catheter inflated at the origin of the left subclavian artery (and protruding in the aortic arch) to both preserve the arterial branch patency and fully exploit the proximal neck. J Cardiovasc Med 2014, 15:000–000
Introduction Thoracic endovascular aortic repair (TEVAR) for aortic lesions located just distally to the (left subclavian artery) left subclavian artery (LSA) may involve scheduled or unscheduled coverage of the origin of the artery. To maintain the branch patency options are represented by surgical debranching techniques or by placement of additional stents. Both options, although gaining consensus, are not free from complications and should be used in experienced centers only in cases when they are strictly necessary. We report a case of a young patient with a chronic rupture of the aortic isthmus and short proximal lending zone treated by TEVAR, using a balloon catheter inflated at the origin of the LSA, to both preserve the arterial branch patency and fully exploit the proximal neck.
Case report A 30-year-old woman was referred to our hospital for a chronic rupture of the aortic isthmus. The asymptomatic pseudoaneurysm, a likely outcome of a car accident that had occurred 12 years earlier, had not been detected in the acute phase. The suspicion of an aortic injury had arisen several years later following a chest radiograph for an acute bronchitis. Subsequent computed tomography (CT) scan showed a chronic aortic rupture (pseudoaneurysm) arising 10 mm distally to the LSA origin and extending in the descending thoracic aorta for 60 mm. Proximal neck length and diameter were 10 and 21 mm, respectively. Aortic angulation at neck level was 1078 (Fig. 1). A TEVAR repair was planned. The challenging proximal landing zone, in terms of length and angulation, left no margin for error in placement of the endograft, so that the 1558-2027 ß 2014 Italian Federation of Cardiology
Keywords: aneurysm, dissection, stent graft, thoracic aorta, thoracic endovascular aneurysm repair Unit of Cardiac Surgery and Radiology Department, Humanitas Clinical and Research Center, Rozzano, Italy Correspondence to Giuseppe Raffa, Unit of Cardiac Surgery, Humanitas Clinical and Research Center, Via Manzoni 56,20089, Rozzano(MI), Italy Tel: +39 02 82244602; fax: +39 02 82244691; e-mail: [email protected] Received 24 October 2013 Revised 16 March 2014 Accepted 18 March 2014
following technique was used during the deployment. After induction of general anesthesia, a 5-F marking flush catheter was advanced into the thoracic aorta from the right common femoral approach for diagnostic assistance. Digital subtraction angiography (DSA) evaluation confirmed the location of the proximal and distal seal zones. Intravenous heparin was administrated. A 10-mm-diameter balloon catheter was introduced through the left brachial artery into the aortic arch over a 0.35-inch guidewire. A 24-F delivery sheath was advanced through the right common femoral access into the abdominal aorta over a stiff, exchange length guidewire. The endograft device (Gore cTAG, 26 mm 10 cm) was advanced into position over the wire under fluoroscopic guidance. Repeat DSA evaluation with magnified oblique (608) projection confirmed placement of the proximal and distal landing zones. The balloon catheter was gently inflated with saline and contrast (1 to 1), with its middle portion located at the LSA ostium, to partially protrude into the aortic arch lumen (Fig. 2a). The marking flush catheter was pulled back to the abdominal aorta and the device was deployed under fluoroscopic guidance gently pushing its proximal flare portion against the balloon. This maneuver allowed exploiting the proximal landing zone along its full length without, at the same time, obstructing the subclavian artery orifice. Postplacement DSA evaluation confirmed appropriate location of the endograft with no endoleak. The stent conformed well to the angulation and the leading edge of the graft material was located immediately on target next to the origin of the subclavian (Fig. 2b). Postprocedure course was uneventful. Postplacement CT scan was obtained prior to discharge (1 week later). No endoleak was DOI:10.2459/JCM.0000000000000104
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
CE: Namrta; JCM-D13-00580; Total nos of Pages: 4;
JCM-D13-00580
2 Journal of Cardiovascular Medicine 2013, Vol 00 No 00
Fig. 1
(a)
(b)
Preoperative CT scan showing (a) length and (b) angulation of the proximal neck. CT, computed tomography.
identified and the stent remained unchanged in position when compared with placement imaging (Fig. 3). Twelve-month CT scan confirmed the correct positioning of the stent with no endoleak (Fig. 4). The study was approved by the institutional review board of our institution.
Discussion Thoracic aortic lesions located just distally to the LSA are often challenging in terms of endograft placement. Whenever possible, coverage of the subclavian should be avoided. Data from the open Eurostar registry of 606 patients revealed a postprocedural stroke rate of 8% after stent LSA unprotected coverage.1 On the contrary, surgical LSA revascularizations (carotid–subclavian bypass or transposition of the subclavian to carotid artery), to
extend the landing zone, are not uneventful procedures too. In 2009, Zipfel et al.2 reported an incidence as high as 21% of complication associated with LSA revascularization, including embolic stroke, phrenic nerve palsies, and lymph fistula. More recently, an endovascular method of maintaining antegrade perfusion to the LSA, known as ‘chimney stenting’ or ‘snorkeling technique’, has been described.3 Although early results show 100% of brunch vessel patency and no early endoleak, larger series and longer follow-up are required to draw conclusion about the reliability of this attractive technique. Our patient presented with a proximal landing zone of 10 mm that is considered less than the minimum length to ensure an adequate proximal sealing. An imperfect
Fig. 2
(a)
(b)
Intra-operative angiography showing (a) the balloon catheter inflated in the left subclavian artery and (b) the correct placement of the graft.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
CE: Namrta; JCM-D13-00580; Total nos of Pages: 4;
JCM-D13-00580
Thoracic endovascular aortic repair Settepani et al. 3
Fig. 3
Predischarge CT scan showing the correct placement of the graft. CT, computed tomography.
positioning of the graft could have led to a type I endoleak or partial coverage of the subclavian artery with risk of recurrent embolization.4 Young patients with chronic rupture of the aortic isthmus and short necks Fig. 4
are frequently encountered. Open surgical repair has been considered the gold standard treatment of thoracic aortic rupture with reduction of mortality and morbidity rate during decades.5 The development of endovascular stent graft technology has been proposed as an alternative less invasive treatment with comparable short6 and even better mid-term results.7,8 Although a landing zone shorter than 20 mm has been regarded as a contra-indication for straight endovascular grafting, the present case report indicates that safe graft placement may be achieved, in case of suboptimal landing zone, by inflating a balloon catheter at the origin of the LSA. This simple maneuver allows better identification of the landmarks of the origin of the subclavian artery, to mechanically prevent the stent graft from covering the origin of the artery and, at the same time, fully exploit the sealing zone. Different techniques have been reported for preserving visceral vessels during endovascular treatment9 and no data are available on the reported approach in thoracic aortic disease. Moreover, this technique allows avoiding additional surgical or endovascular maneuvers on the subclavian artery to maintain patency. We do not recommend this maneuver in elderly patients or in the case of extended atherosclerotic and/or calcific aortic arch in which lesions located at the origin of the subclavian artery could result in cerebral and/or upper limb emolization during or soon afterwards ballooning. On the contrary, young patients with chronic rupture of the isthmus usually have a normal aorta except for the localized target lesion. However, this technique should be used with caution even in young patients in whom particular anatomical conditions such as proximal angled neck or bovine arch may result in proximal type I endoleak, graft migration or carotid artery dissection. In summary, an inflated balloon catheter is a simple and easily reproducible technique that permits, in the case of selected challenging proximal neck, the preservation of LSA patency and, at the same time, fully exploits the sealing zone. Nevertheless, to definitely validate this maneuver, a larger number of cases and a longer followup (mainly in cases of very long life expectancy) are two necessary conditions.
Acknowledgements The authors declare no funding sources and no actual or potential competing financial interests.
References 1
2
Six-month 3D CT scan confirming the correct placement of the graft. 3D, three-dimensional; CT, computed tomography.
3
Buth J, Harris PL, Hobo R, et al. Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vasc Surg 2007; 46:1103–1110. Zipfel B, Buz S, Hammerschmidt R, et al. Occlusion of the left subclavian artery with stent grafts is safer with protective reconstruction. Ann Thorac Surg 2009; 88:498–504. Baldwin ZK, Chuter TA, Hiramoto JS, et al. Double-barrel technique for preservation of aortic arch branches during thoracic endovascular aortic repair. Ann Vasc Surg 2008; 22:703–709.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
CE: Namrta; JCM-D13-00580; Total nos of Pages: 4;
JCM-D13-00580
4 Journal of Cardiovascular Medicine 2013, Vol 00 No 00
4
5 6
Chaudhuri A, Tibballs J, Nadkarni S, et al. Digital embolization due to partially uncovered left subclavian artery post TEVAR: management with amplatzer vascular plug occlusion. J Endovasc Ther 2007; 14:257–259. Jamieson WR, Janusz MT, Gudas VM, et al. Traumatic rupture of the thoracic aorta: third decade of experience. Am J Surg 2002; 183:571–575. Amabile P, Collart F, Gariboldi V, et al. Surgical versus endovascular treatment of traumatic thoracic aortic rupture. J Vasc Surg 2004; 40:873– 879.
7
8 9
Ott MC, Stewart TC, Lawlor DK, et al. Management of blunt thoracic aortic injuries: endovascular stents versus open repair. J Trauma 2004; 57:565– 570. Yamane BH, Tefera G, Hoch JR, et al. Blunt thoracic aortic injury: open or stent graft repair? Surgery 2008; 144:575–580. Moulakakis KG, Mylonas SN, Avgerinos E, et al. The chimney graft technique for preserving visceral vessels during endovascular treatment of aortic pathologies. J Vasc Surg 2012; 55:1497–1503.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
JCM-D13-00580
Perspective article
Preserving the left subclavian artery patency in challenging proximal neck during thoracic endovascular aortic repair Fabrizio Settepani, Giuseppe Maria Raffa, Pietro Giorgio Malvindi, Giuseppe Tarelli, Giorgio Brambilla and Vittorio Pedicini Coverage of the left subclavian artery in thoracic endovascular aortic repair is still a controversial procedure. We report a case of 30-year-old patient with a chronic rupture of the aortic isthmus and short proximal lending zone (10 mm) treated by thoracic endovascular aortic repair using a balloon catheter inflated at the origin of the left subclavian artery (and protruding in the aortic arch) to both preserve the arterial branch patency and fully exploit the proximal neck. J Cardiovasc Med 2014, 15:000–000
Introduction Thoracic endovascular aortic repair (TEVAR) for aortic lesions located just distally to the (left subclavian artery) left subclavian artery (LSA) may involve scheduled or unscheduled coverage of the origin of the artery. To maintain the branch patency options are represented by surgical debranching techniques or by placement of additional stents. Both options, although gaining consensus, are not free from complications and should be used in experienced centers only in cases when they are strictly necessary. We report a case of a young patient with a chronic rupture of the aortic isthmus and short proximal lending zone treated by TEVAR, using a balloon catheter inflated at the origin of the LSA, to both preserve the arterial branch patency and fully exploit the proximal neck.
Case report A 30-year-old woman was referred to our hospital for a chronic rupture of the aortic isthmus. The asymptomatic pseudoaneurysm, a likely outcome of a car accident that had occurred 12 years earlier, had not been detected in the acute phase. The suspicion of an aortic injury had arisen several years later following a chest radiograph for an acute bronchitis. Subsequent computed tomography (CT) scan showed a chronic aortic rupture (pseudoaneurysm) arising 10 mm distally to the LSA origin and extending in the descending thoracic aorta for 60 mm. Proximal neck length and diameter were 10 and 21 mm, respectively. Aortic angulation at neck level was 1078 (Fig. 1). A TEVAR repair was planned. The challenging proximal landing zone, in terms of length and angulation, left no margin for error in placement of the endograft, so that the 1558-2027 ß 2014 Italian Federation of Cardiology
Keywords: aneurysm, dissection, stent graft, thoracic aorta, thoracic endovascular aneurysm repair Unit of Cardiac Surgery and Radiology Department, Humanitas Clinical and Research Center, Rozzano, Italy Correspondence to Giuseppe Raffa, Unit of Cardiac Surgery, Humanitas Clinical and Research Center, Via Manzoni 56,20089, Rozzano(MI), Italy Tel: +39 02 82244602; fax: +39 02 82244691; e-mail: [email protected] Received 24 October 2013 Revised 16 March 2014 Accepted 18 March 2014
following technique was used during the deployment. After induction of general anesthesia, a 5-F marking flush catheter was advanced into the thoracic aorta from the right common femoral approach for diagnostic assistance. Digital subtraction angiography (DSA) evaluation confirmed the location of the proximal and distal seal zones. Intravenous heparin was administrated. A 10-mm-diameter balloon catheter was introduced through the left brachial artery into the aortic arch over a 0.35-inch guidewire. A 24-F delivery sheath was advanced through the right common femoral access into the abdominal aorta over a stiff, exchange length guidewire. The endograft device (Gore cTAG, 26 mm 10 cm) was advanced into position over the wire under fluoroscopic guidance. Repeat DSA evaluation with magnified oblique (608) projection confirmed placement of the proximal and distal landing zones. The balloon catheter was gently inflated with saline and contrast (1 to 1), with its middle portion located at the LSA ostium, to partially protrude into the aortic arch lumen (Fig. 2a). The marking flush catheter was pulled back to the abdominal aorta and the device was deployed under fluoroscopic guidance gently pushing its proximal flare portion against the balloon. This maneuver allowed exploiting the proximal landing zone along its full length without, at the same time, obstructing the subclavian artery orifice. Postplacement DSA evaluation confirmed appropriate location of the endograft with no endoleak. The stent conformed well to the angulation and the leading edge of the graft material was located immediately on target next to the origin of the subclavian (Fig. 2b). Postprocedure course was uneventful. Postplacement CT scan was obtained prior to discharge (1 week later). No endoleak was DOI:10.2459/JCM.0000000000000104
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
CE: Namrta; JCM-D13-00580; Total nos of Pages: 4;
JCM-D13-00580
2 Journal of Cardiovascular Medicine 2013, Vol 00 No 00
Fig. 1
(a)
(b)
Preoperative CT scan showing (a) length and (b) angulation of the proximal neck. CT, computed tomography.
identified and the stent remained unchanged in position when compared with placement imaging (Fig. 3). Twelve-month CT scan confirmed the correct positioning of the stent with no endoleak (Fig. 4). The study was approved by the institutional review board of our institution.
Discussion Thoracic aortic lesions located just distally to the LSA are often challenging in terms of endograft placement. Whenever possible, coverage of the subclavian should be avoided. Data from the open Eurostar registry of 606 patients revealed a postprocedural stroke rate of 8% after stent LSA unprotected coverage.1 On the contrary, surgical LSA revascularizations (carotid–subclavian bypass or transposition of the subclavian to carotid artery), to
extend the landing zone, are not uneventful procedures too. In 2009, Zipfel et al.2 reported an incidence as high as 21% of complication associated with LSA revascularization, including embolic stroke, phrenic nerve palsies, and lymph fistula. More recently, an endovascular method of maintaining antegrade perfusion to the LSA, known as ‘chimney stenting’ or ‘snorkeling technique’, has been described.3 Although early results show 100% of brunch vessel patency and no early endoleak, larger series and longer follow-up are required to draw conclusion about the reliability of this attractive technique. Our patient presented with a proximal landing zone of 10 mm that is considered less than the minimum length to ensure an adequate proximal sealing. An imperfect
Fig. 2
(a)
(b)
Intra-operative angiography showing (a) the balloon catheter inflated in the left subclavian artery and (b) the correct placement of the graft.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
CE: Namrta; JCM-D13-00580; Total nos of Pages: 4;
JCM-D13-00580
Thoracic endovascular aortic repair Settepani et al. 3
Fig. 3
Predischarge CT scan showing the correct placement of the graft. CT, computed tomography.
positioning of the graft could have led to a type I endoleak or partial coverage of the subclavian artery with risk of recurrent embolization.4 Young patients with chronic rupture of the aortic isthmus and short necks Fig. 4
are frequently encountered. Open surgical repair has been considered the gold standard treatment of thoracic aortic rupture with reduction of mortality and morbidity rate during decades.5 The development of endovascular stent graft technology has been proposed as an alternative less invasive treatment with comparable short6 and even better mid-term results.7,8 Although a landing zone shorter than 20 mm has been regarded as a contra-indication for straight endovascular grafting, the present case report indicates that safe graft placement may be achieved, in case of suboptimal landing zone, by inflating a balloon catheter at the origin of the LSA. This simple maneuver allows better identification of the landmarks of the origin of the subclavian artery, to mechanically prevent the stent graft from covering the origin of the artery and, at the same time, fully exploit the sealing zone. Different techniques have been reported for preserving visceral vessels during endovascular treatment9 and no data are available on the reported approach in thoracic aortic disease. Moreover, this technique allows avoiding additional surgical or endovascular maneuvers on the subclavian artery to maintain patency. We do not recommend this maneuver in elderly patients or in the case of extended atherosclerotic and/or calcific aortic arch in which lesions located at the origin of the subclavian artery could result in cerebral and/or upper limb emolization during or soon afterwards ballooning. On the contrary, young patients with chronic rupture of the isthmus usually have a normal aorta except for the localized target lesion. However, this technique should be used with caution even in young patients in whom particular anatomical conditions such as proximal angled neck or bovine arch may result in proximal type I endoleak, graft migration or carotid artery dissection. In summary, an inflated balloon catheter is a simple and easily reproducible technique that permits, in the case of selected challenging proximal neck, the preservation of LSA patency and, at the same time, fully exploits the sealing zone. Nevertheless, to definitely validate this maneuver, a larger number of cases and a longer followup (mainly in cases of very long life expectancy) are two necessary conditions.
Acknowledgements The authors declare no funding sources and no actual or potential competing financial interests.
References 1
2
Six-month 3D CT scan confirming the correct placement of the graft. 3D, three-dimensional; CT, computed tomography.
3
Buth J, Harris PL, Hobo R, et al. Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vasc Surg 2007; 46:1103–1110. Zipfel B, Buz S, Hammerschmidt R, et al. Occlusion of the left subclavian artery with stent grafts is safer with protective reconstruction. Ann Thorac Surg 2009; 88:498–504. Baldwin ZK, Chuter TA, Hiramoto JS, et al. Double-barrel technique for preservation of aortic arch branches during thoracic endovascular aortic repair. Ann Vasc Surg 2008; 22:703–709.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
CE: Namrta; JCM-D13-00580; Total nos of Pages: 4;
JCM-D13-00580
4 Journal of Cardiovascular Medicine 2013, Vol 00 No 00
4
5 6
Chaudhuri A, Tibballs J, Nadkarni S, et al. Digital embolization due to partially uncovered left subclavian artery post TEVAR: management with amplatzer vascular plug occlusion. J Endovasc Ther 2007; 14:257–259. Jamieson WR, Janusz MT, Gudas VM, et al. Traumatic rupture of the thoracic aorta: third decade of experience. Am J Surg 2002; 183:571–575. Amabile P, Collart F, Gariboldi V, et al. Surgical versus endovascular treatment of traumatic thoracic aortic rupture. J Vasc Surg 2004; 40:873– 879.
7
8 9
Ott MC, Stewart TC, Lawlor DK, et al. Management of blunt thoracic aortic injuries: endovascular stents versus open repair. J Trauma 2004; 57:565– 570. Yamane BH, Tefera G, Hoch JR, et al. Blunt thoracic aortic injury: open or stent graft repair? Surgery 2008; 144:575–580. Moulakakis KG, Mylonas SN, Avgerinos E, et al. The chimney graft technique for preserving visceral vessels during endovascular treatment of aortic pathologies. J Vasc Surg 2012; 55:1497–1503.
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
