Retrograde Type B Aortic Dissection as a Complication of Standard Endovascular Aortic Repair Pasqualino Sirignano, Chiara Pranteda, Laura Capoccia, Danilo Menna, Wassim Mansour, and Francesco Speziale, Rome, Italy
Endovascular repair (EVAR) for abdominal aortic aneurysms (AAAs) is becoming the standard of practice in most vascular centers, even if some concerns remain about the occurrence of early and long-term failure and reintervention. A rare but potential catastrophic event is represented by retrograde type B aortic dissection (RTBAD). We report 2 cases of RTBAD after 425 standard EVARs performed in our institution. Both patients were treated for AAA without perioperative complication, and in both the patients, the presence of a preexisting disease of the thoracic aortic wall (ulcerated plaque in 1 case and aortic ectasia in the other) may have played an important role in the rapid evolution toward an early onset of the dissection. Only few cases of type B dissection after EVAR have been reported in literature, and the etiology of this complication remains uncertain. For the first time, our experience highlights the possible etiologic role of preexisting lesions of the thoracic aorta. In these cases, the only possible strategy may be to carefully study the entire aorta before an EVAR procedure, eventually switching the indication to an open surgical repair or carrying out a more aggressive management, treating the defects of the thoracic aorta.
The endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs) has become an established practice in patients with a favorable anatomy1 and a feasible technique even in case of challenging anatomies.2 The main problem related to EVAR remains the occurrences of early and long-term failure requiring reintervention.3 A rare but potentially catastrophic event is represented by retrograde type B aortic dissection (RTBAD). In literature, few cases of acute aortic dissection are reported after EVAR procedure. We report 2 Vascular and Endovascular Surgery Division, Department of Surgery ‘‘Paride Stefanini’’, ‘‘Sapienza’’ University of Rome, Policlinico Umberto I, Rome, Italy. Correspondence to: Pasqualino Sirignano, MD, Vascular and Endovascular Surgery Division, Department of Surgery ‘‘Paride Stefanini’’, Policlinico Umberto I, ‘‘Sapienza’’ University of Rome, Viale del Policlinico, 155, Rome 00161, Italy; E-mail: [email protected] Ann Vasc Surg 2015; 29: 127.e5e127.e9 http://dx.doi.org/10.1016/j.avsg.2014.08.011 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: June 24, 2014; manuscript accepted: August 7, 2014; published online: October 7, 2014.
cases of acute RTBAD after standard EVAR performed at our center.
CASE 1 A 68-year-old man was admitted to the emergency room of our hospital for abdominal pain radiating in the lumbar region associated with hypertensive crisis (arterial blood pressure, 230/120 mm Hg). In his medical history, there was no risk factor except for smoking habits. Blood tests were normal, except mild increase in serum creatinine (1.8 mg/dL). The patient underwent a computed tomography angiography (CTA) documenting the presence of an ulcerated plaque in the descending thoracic aorta below the left subclavian artery, associated with AAA with a maximum diameter of 70 mm. Proximal aortic neck measured 26 mm in diameter and 6 mm in length. Kinking of both iliac axis and right common iliac artery ectasia (maximum diameter: 24 mm) were also present. The patient was therefore referred to emergency EVAR with bifurcated aortic stent graft (Endurant 127.e5
127.e6 Case reports
Annals of Vascular Surgery
Fig. 1. Case 1, Multiplanar reconstruction showing the aorta before (A) and after (B) EVAR.
II 32-16-145 mm + 16-13-93 mm + 16-16-156 mm; Medtronic Cardiovascular, Santa Rosa, CA). The iliac branches were placed using the crossedlimb configuration4 to accommodate the endograft to the iliac anatomy. The completion angiography showed the good positioning of the endoprosthesis in the absence of endoleaks or other complications. Before hospital discharge, a new CTA showed good positioning of the endoprosthesis, without any endoleak, and no new alteration at the level of the thoracic aorta. The patient was discharged on postoperative day 8 in good general condition, with complete pain relief and normalization of blood pressure after adequate antihypertensive therapy. One month after surgery, the patient complained about the sudden onset of chest pain and new increase in arterial blood pressure (blood pressure 160/80 mm Hg). A new CTA (Fig. 1) showed the presence of RTBAD that extended from the origin of the left subclavian artery to the distal third of the descending thoracic aorta, associated with aneurysmal dilatation (maximum diameter, 40 mm). Patient was newly referred to surgery, undergoing a left carotid-subclavian bypass followed by endovascular exclusion of the thoracic aneurysm (Zenith Alpha 36-32209 mm; Cook Medical Inc, Bloomington, IN). Postoperative course was uneventful and the
patient was discharged in postoperative day 5 in good general condition. At 3-month follow-up, a new CTA showed good positioning of both the endografts, without endoleak or residual dissection.
CASE 2 A 51-year-old man underwent scheduled CTA for chronic pancreatitis, showing a nonruptured AAA (maximum diameter, 63 mm), an aneurysm (maximum diameter, 22 mm) of the right internal iliac artery (IIA), and an ectasia (maximum diameter, 40 mm) of the aorta just above the celiac trunk. Infrarenal aortic neck measured 27 mm in diameter and 22 mm in length. The patient was referred to our unit for AAA treatment. He reported no cardiovascular risk factor, and preoperative assessment was normal. After the patient refused an open surgical repair, a standard EVAR procedure (Excluder C3 31-14-130 mm + 16-20-200 mm + 16-18-100 mm; W.L. Gore & Associates, Flagstaff, AZ) was performed to exclude the infrarenal aneurysm covering the ostium of the right IIA. Postoperative course was uneventful, and the patient was discharged on postoperative day 3. The 1-month follow-up CTA showed the good positioning of the stent graft and the complete exclusion of the aneurysmal sac and of the IIA aneurysm.
Vol. 29, No. 1, January 2015
Case reports 127.e7
Fig. 2. Case 2, axial images and Multiplanar reconstruction showing the aorta before (A) and after (B) EVAR.
Six months after the index procedure, the patient came to our emergent department for the sudden onset of anterior thoracic pain in absence of other clinical signs or symptoms; CTA (Fig. 2) showed the presence of dissecting aneurysm of the descending thoracic aorta (51 mm) extending from its third portion to the renal arteries, AAA was completely shrinked. Because of the young age, the absence of malperfusion, hypertension, or pain, the patient was medically treated, postponing the aneurysm repair. At 5-month follow-up visit, the patient was fine and a new CTA demonstrated the stabilization of the disease without further aortic dilatation.
DISCUSSION Aortic dissection is consequent to a lesion of the aortic wall accompanied by weakening of the media, risk of aortic rupture, and malperfusion with high morbidity and mortality rates.5 Retrograde dissection after thoracic stent-graft implantation has been reported in up to 2.4% of the cases,6 it can also complicate renal angioplasty, iliac artery stenting, coronary intervention, and aortic balloon dilatation for coarctation.7e10 Incidence of RTBAD after EVAR is not assessable: at our best knowledge, only few cases have been reported in literature (Table I).11e19 The etiology of this complication remains uncertain. Aortic dissection may be spontaneous, starting
at the level of the subclavian artery with a reentry tear at level of distal aorta or of the iliac arteries, complicating the course of the dissection. In some cases, especially when dissection occurs in the very early postoperative period, technical aspects and device-related characteristics could determine its onset. Direct damage by super-stiff guidewires or by balloon catheters at the level of the thoracic aorta are frequently advocated. For these reasons, several authors,12,13 as we use to, routinely use a soft-angled guidewire under fluoroscopy, followed by a pigtail catheter and subsequent wire exchange to minimize the aortic trauma. Other anatomic factors likely to induce dissection may exist, including the calcification of the aorta just above the level of the renal arteries. Another possible risk factor could be the irregular-shaped infrarenal neck and substantial endograft oversizing in the narrow-most segment.12 Device-specific factors could also contribute to the dissection: 8 out of 10 stent grafts used in the previously published experiences had a proximal bare stent with anchoring barbs.12e19 Four cases of dissection were evident yet in the first week after EVAR,11,14,16,17 but in most cases, and also in our experience, dissection was evident at least 1 month after the abdominal procedure (Table I).12,13,15,18,19 These findings could support the hypothesis of a complex biomechanical interaction between the endograft and the aortic wall as cause of the dissection, rather than a direct iatrogenic trauma.
127.e8 Case reports
Table I. Post-EVAR dissection, review of the literature First author (year)
Age, years
Gender
Device
Interval
Symptoms
Treatment
Outcome
Girardi11 (1999)
76
M
Custom-made endograft
2 Days
Chest pain
Ok
Haulon12 (2001)
53
W
Excluder (Gore)
20 Weeks
Iyer13 (2009) Tolenaar14 (2011)
77 82
M M
Zenith Flex (Cook) Endurant (Medtronic)
12 Weeks 2 Days
Bilateral lower extremity pain Abdominal and back pain Chest pain
MT, after 4 months or type I TAAA MT
Pulli15 (2011)
69
M
108 Weeks
Chest pain
Khanbhai16 (2012)
Mamopoulos17 (2013) Yamamoto18 (2013)
78 84 81 80 94
M M M M M
Zenith Flex + Iliac Branch (Cook) Zenith (Cook) Endurant (Medtronic) Talent (Medtronic) Endurant (Medtronic) Zenith Flex (Cook)
6 Weeks 1 Day 3 Weeks 2 Days 72 Weeks
Psacharopulo19 (2014)
75
M
Excluder (Gore)
58 Weeks
Current experience (2014)
68 51
M M
Endurant II (Medtronic) Excluder C3 (Gore)
4 Weeks 24 Weeks
Chest pain Abdominal distention Chest pain Asymptomatic Abdominal pain and massive retroperitoneal hematoma Back and abdominal pain and lower limb ischemia Chest pain Chest pain
Valiant SG Fenestration of the intimal flap TX2 SG and BMS
Ok Ok
MT MT MT MT MT
Ok Ok Ok Ok Death
OR
Death
Zenith Alpha SG MT
Ok Ok
Ok
Annals of Vascular Surgery
M, male; MT, medical therapy; TAAA, thoracoabdominal aortic aneurysm; OR, open repair; SG, stent graft; BMS, bare metal stent.
Death
Vol. 29, No. 1, January 2015
Biomechanical forces alone, however, may not justify the dissection, so other factors (or, at least, cofactors) should be advocated. We report this complication only in 0.47% (2 of 425) of cases of EVARs consecutively performed between January 2008 and December 2013. Both our patients presented focal lesions at descending thoracic aorta: the first one developed an RTBAD with proximal entry tear located distally to left subclavian artery, where an ulcerated plaque was detected by preoperative CTA. The latter developed the same complication at visceral aorta level, where aortic ectasia was evident. It should be reasonable that, although without any clear evidence, these preexisting aortic defects could play a role in etiopathogenesis of RTBAD. It should be considered the possibility that heavily calcified plaques at thoracic level, such as the one described in the first patient, may behave like a penetrating aortic ulcer and consequently require a more aggressive treatment. Although the few reported cases do not allow identifying specific pathogenetic mechanisms, our limited experience may suggest aortic malacia as a different risk factor for the development of RTBAD after EVAR. Regardless of the etiopathogenetic mechanism, once established, RTBAD is a devastating and a life-threatening complication: since aortic dilatation and rupture, visceral and spinal ischemia have been described.11,12,19 It is mandatory to promptly identify all potential risk factors to avoid their occurrence. In conclusion, from the data currently available in the literature, there are no predictive factors for this rare but life-threatening complication. For the first time, our experience highlights the possible etiologic role of preexisting lesions of the thoracic aorta. For this reason, even on the basis of a limited experience, the only possible strategy might be to study carefully the entire aorta before an EVAR procedure, and in the case of associated lesions, switch the indication to a surgical repair or carry out a more aggressive management, treating the defects of the thoracic aorta. REFERENCES 1. Moll FL, Powell JT, Fraedrich G, et al. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg 2011;41(Suppl 1):S1e58.
Case reports 127.e9
2. Setacci F, Sirignano P, de Donato G, et al. AAA with a challenging neck: early outcomes using the Endurant stent-graft system. Eur J Vasc Endovasc Surg 2012;44:274e9. 3. Paravastu SC, Jayarajasingam R, Cottam R, et al. Endovascular repair of abdominal aortic aneurysm. Cochrane Database Syst Rev 2014;CD004178. 4. Georgiadis GS, Georgakarakos EI, Antoniou GA, et al. Clinical outcomes after crossed-limb vs. conventional endograft configuration in endovascular AAA repair. J Endovasc Ther 2013;20:853e62. 5. Setacci F, Sirignano P, de Donato G, et al. Acute aortic dissection: natural history and classification. J Cardiovasc Surg (Torino) 2010;51:641e6. 6. Lu S, Lai H, Wang C, et al. Surgical treatment for retrograde type A aortic dissection after endovascular stent graft placement for type B dissection. Interact Cardiovasc Thorac Surg 2012;14:538e42. 7. Haesemeyer SW, Vedantham S, Braverman A. Renal artery stent placement complicated by development of a type B aortic dissection. Cardiovasc Intervent Radiol 2005;28: 98e101. 8. Cisek PL, McKittrick JE. Retrograde aortic dissection after bilateral iliac artery stenting: a case report and review of the literature. Ann Vasc Surg 1995;9:280e4. 9. Ochi M, Yamauchi S, Yajima T, et al. Aortic dissection extending from the left coronary artery during percutaneous coronary angioplasty. Ann Thorac Surg 1996;62:1180e2. 10. Beitzke A, Stein JI, Gamillscheg A, et al. Dissection of the descending aorta after balloon angioplasty of native coarctation. Pediatr Cardiol 1997;18:222e5. 11. Girardi LN, Bush HL Jr. Type B aortic dissection and thoracoabdominal aneurysm formation after endoluminal stent repair of abdominal aortic aneurysm. J Vasc Surg 1999;29:936e8. 12. Haulon S, Greenberg RK, Khwaja J, et al. Aortic dissection in the setting of an infrarenal endoprosthesis: a fatal combination. J Vasc Surg 2003;38:1121e4. 13. Iyer V, Rigby M, Vrabec G Sr. Type B aortic dissection after endovascular abdominal aortic aneurysm repair causing endograft collapse and severe malperfusion. J Vasc Surg 2009;50:413e6. 14. Tolenaar JL, van Keulen JW, Vonken EJ, et al. Fenestration of an iatrogenic aortic dissection after endovascular aneurysm repair. J Endovasc Ther 2011;18:256e60. 15. Pulli R, Fargion A, Pratesi G, et al. Aortic type B dissection with acute expansion of iliac artery aneurysm in previous endovascular repair with iliac branched graft. J Vasc Surg 2011;54:1788e91. 16. Khanbhai M, Ghosh J, Ashleigh R, et al. Type B aortic dissection after standard endovascular repair of abdominal aortic aneurysm. BMJ Case Rep 2013;9:2013. 17. Mamopoulos AT, Nowak T, Luther B. Retrograde ascending Stanford B aortic dissection complicating a routine infrarenal endovascular aortic reconstruction. J Vasc Surg 2013;58:208e11. 18. Yamamoto S, Hoshina K, Takazawa Y, et al. Aortic dissection occurring 18 months after successful endovascular repair in an anatomically difficult case of abdominal aortic aneurysm. Case Rep Vasc Med 2013;2013:412708. 19. Psacharopulo D, Ferrero E, Viazzo A, et al. Abdominal aortic endograft collapse due to false lumen radial force of an acute type B aortic dissection. Ann Vasc Surg. http://dx.doi.org/ 10.1016/j.avsg.2014.06.067. [Epub ahead of print].
Endovascular repair (EVAR) for abdominal aortic aneurysms (AAAs) is becoming the standard of practice in most vascular centers, even if some concerns remain about the occurrence of early and long-term failure and reintervention. A rare but potential catastrophic event is represented by retrograde type B aortic dissection (RTBAD). We report 2 cases of RTBAD after 425 standard EVARs performed in our institution. Both patients were treated for AAA without perioperative complication, and in both the patients, the presence of a preexisting disease of the thoracic aortic wall (ulcerated plaque in 1 case and aortic ectasia in the other) may have played an important role in the rapid evolution toward an early onset of the dissection. Only few cases of type B dissection after EVAR have been reported in literature, and the etiology of this complication remains uncertain. For the first time, our experience highlights the possible etiologic role of preexisting lesions of the thoracic aorta. In these cases, the only possible strategy may be to carefully study the entire aorta before an EVAR procedure, eventually switching the indication to an open surgical repair or carrying out a more aggressive management, treating the defects of the thoracic aorta.
The endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs) has become an established practice in patients with a favorable anatomy1 and a feasible technique even in case of challenging anatomies.2 The main problem related to EVAR remains the occurrences of early and long-term failure requiring reintervention.3 A rare but potentially catastrophic event is represented by retrograde type B aortic dissection (RTBAD). In literature, few cases of acute aortic dissection are reported after EVAR procedure. We report 2 Vascular and Endovascular Surgery Division, Department of Surgery ‘‘Paride Stefanini’’, ‘‘Sapienza’’ University of Rome, Policlinico Umberto I, Rome, Italy. Correspondence to: Pasqualino Sirignano, MD, Vascular and Endovascular Surgery Division, Department of Surgery ‘‘Paride Stefanini’’, Policlinico Umberto I, ‘‘Sapienza’’ University of Rome, Viale del Policlinico, 155, Rome 00161, Italy; E-mail: [email protected] Ann Vasc Surg 2015; 29: 127.e5e127.e9 http://dx.doi.org/10.1016/j.avsg.2014.08.011 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: June 24, 2014; manuscript accepted: August 7, 2014; published online: October 7, 2014.
cases of acute RTBAD after standard EVAR performed at our center.
CASE 1 A 68-year-old man was admitted to the emergency room of our hospital for abdominal pain radiating in the lumbar region associated with hypertensive crisis (arterial blood pressure, 230/120 mm Hg). In his medical history, there was no risk factor except for smoking habits. Blood tests were normal, except mild increase in serum creatinine (1.8 mg/dL). The patient underwent a computed tomography angiography (CTA) documenting the presence of an ulcerated plaque in the descending thoracic aorta below the left subclavian artery, associated with AAA with a maximum diameter of 70 mm. Proximal aortic neck measured 26 mm in diameter and 6 mm in length. Kinking of both iliac axis and right common iliac artery ectasia (maximum diameter: 24 mm) were also present. The patient was therefore referred to emergency EVAR with bifurcated aortic stent graft (Endurant 127.e5
127.e6 Case reports
Annals of Vascular Surgery
Fig. 1. Case 1, Multiplanar reconstruction showing the aorta before (A) and after (B) EVAR.
II 32-16-145 mm + 16-13-93 mm + 16-16-156 mm; Medtronic Cardiovascular, Santa Rosa, CA). The iliac branches were placed using the crossedlimb configuration4 to accommodate the endograft to the iliac anatomy. The completion angiography showed the good positioning of the endoprosthesis in the absence of endoleaks or other complications. Before hospital discharge, a new CTA showed good positioning of the endoprosthesis, without any endoleak, and no new alteration at the level of the thoracic aorta. The patient was discharged on postoperative day 8 in good general condition, with complete pain relief and normalization of blood pressure after adequate antihypertensive therapy. One month after surgery, the patient complained about the sudden onset of chest pain and new increase in arterial blood pressure (blood pressure 160/80 mm Hg). A new CTA (Fig. 1) showed the presence of RTBAD that extended from the origin of the left subclavian artery to the distal third of the descending thoracic aorta, associated with aneurysmal dilatation (maximum diameter, 40 mm). Patient was newly referred to surgery, undergoing a left carotid-subclavian bypass followed by endovascular exclusion of the thoracic aneurysm (Zenith Alpha 36-32209 mm; Cook Medical Inc, Bloomington, IN). Postoperative course was uneventful and the
patient was discharged in postoperative day 5 in good general condition. At 3-month follow-up, a new CTA showed good positioning of both the endografts, without endoleak or residual dissection.
CASE 2 A 51-year-old man underwent scheduled CTA for chronic pancreatitis, showing a nonruptured AAA (maximum diameter, 63 mm), an aneurysm (maximum diameter, 22 mm) of the right internal iliac artery (IIA), and an ectasia (maximum diameter, 40 mm) of the aorta just above the celiac trunk. Infrarenal aortic neck measured 27 mm in diameter and 22 mm in length. The patient was referred to our unit for AAA treatment. He reported no cardiovascular risk factor, and preoperative assessment was normal. After the patient refused an open surgical repair, a standard EVAR procedure (Excluder C3 31-14-130 mm + 16-20-200 mm + 16-18-100 mm; W.L. Gore & Associates, Flagstaff, AZ) was performed to exclude the infrarenal aneurysm covering the ostium of the right IIA. Postoperative course was uneventful, and the patient was discharged on postoperative day 3. The 1-month follow-up CTA showed the good positioning of the stent graft and the complete exclusion of the aneurysmal sac and of the IIA aneurysm.
Vol. 29, No. 1, January 2015
Case reports 127.e7
Fig. 2. Case 2, axial images and Multiplanar reconstruction showing the aorta before (A) and after (B) EVAR.
Six months after the index procedure, the patient came to our emergent department for the sudden onset of anterior thoracic pain in absence of other clinical signs or symptoms; CTA (Fig. 2) showed the presence of dissecting aneurysm of the descending thoracic aorta (51 mm) extending from its third portion to the renal arteries, AAA was completely shrinked. Because of the young age, the absence of malperfusion, hypertension, or pain, the patient was medically treated, postponing the aneurysm repair. At 5-month follow-up visit, the patient was fine and a new CTA demonstrated the stabilization of the disease without further aortic dilatation.
DISCUSSION Aortic dissection is consequent to a lesion of the aortic wall accompanied by weakening of the media, risk of aortic rupture, and malperfusion with high morbidity and mortality rates.5 Retrograde dissection after thoracic stent-graft implantation has been reported in up to 2.4% of the cases,6 it can also complicate renal angioplasty, iliac artery stenting, coronary intervention, and aortic balloon dilatation for coarctation.7e10 Incidence of RTBAD after EVAR is not assessable: at our best knowledge, only few cases have been reported in literature (Table I).11e19 The etiology of this complication remains uncertain. Aortic dissection may be spontaneous, starting
at the level of the subclavian artery with a reentry tear at level of distal aorta or of the iliac arteries, complicating the course of the dissection. In some cases, especially when dissection occurs in the very early postoperative period, technical aspects and device-related characteristics could determine its onset. Direct damage by super-stiff guidewires or by balloon catheters at the level of the thoracic aorta are frequently advocated. For these reasons, several authors,12,13 as we use to, routinely use a soft-angled guidewire under fluoroscopy, followed by a pigtail catheter and subsequent wire exchange to minimize the aortic trauma. Other anatomic factors likely to induce dissection may exist, including the calcification of the aorta just above the level of the renal arteries. Another possible risk factor could be the irregular-shaped infrarenal neck and substantial endograft oversizing in the narrow-most segment.12 Device-specific factors could also contribute to the dissection: 8 out of 10 stent grafts used in the previously published experiences had a proximal bare stent with anchoring barbs.12e19 Four cases of dissection were evident yet in the first week after EVAR,11,14,16,17 but in most cases, and also in our experience, dissection was evident at least 1 month after the abdominal procedure (Table I).12,13,15,18,19 These findings could support the hypothesis of a complex biomechanical interaction between the endograft and the aortic wall as cause of the dissection, rather than a direct iatrogenic trauma.
127.e8 Case reports
Table I. Post-EVAR dissection, review of the literature First author (year)
Age, years
Gender
Device
Interval
Symptoms
Treatment
Outcome
Girardi11 (1999)
76
M
Custom-made endograft
2 Days
Chest pain
Ok
Haulon12 (2001)
53
W
Excluder (Gore)
20 Weeks
Iyer13 (2009) Tolenaar14 (2011)
77 82
M M
Zenith Flex (Cook) Endurant (Medtronic)
12 Weeks 2 Days
Bilateral lower extremity pain Abdominal and back pain Chest pain
MT, after 4 months or type I TAAA MT
Pulli15 (2011)
69
M
108 Weeks
Chest pain
Khanbhai16 (2012)
Mamopoulos17 (2013) Yamamoto18 (2013)
78 84 81 80 94
M M M M M
Zenith Flex + Iliac Branch (Cook) Zenith (Cook) Endurant (Medtronic) Talent (Medtronic) Endurant (Medtronic) Zenith Flex (Cook)
6 Weeks 1 Day 3 Weeks 2 Days 72 Weeks
Psacharopulo19 (2014)
75
M
Excluder (Gore)
58 Weeks
Current experience (2014)
68 51
M M
Endurant II (Medtronic) Excluder C3 (Gore)
4 Weeks 24 Weeks
Chest pain Abdominal distention Chest pain Asymptomatic Abdominal pain and massive retroperitoneal hematoma Back and abdominal pain and lower limb ischemia Chest pain Chest pain
Valiant SG Fenestration of the intimal flap TX2 SG and BMS
Ok Ok
MT MT MT MT MT
Ok Ok Ok Ok Death
OR
Death
Zenith Alpha SG MT
Ok Ok
Ok
Annals of Vascular Surgery
M, male; MT, medical therapy; TAAA, thoracoabdominal aortic aneurysm; OR, open repair; SG, stent graft; BMS, bare metal stent.
Death
Vol. 29, No. 1, January 2015
Biomechanical forces alone, however, may not justify the dissection, so other factors (or, at least, cofactors) should be advocated. We report this complication only in 0.47% (2 of 425) of cases of EVARs consecutively performed between January 2008 and December 2013. Both our patients presented focal lesions at descending thoracic aorta: the first one developed an RTBAD with proximal entry tear located distally to left subclavian artery, where an ulcerated plaque was detected by preoperative CTA. The latter developed the same complication at visceral aorta level, where aortic ectasia was evident. It should be reasonable that, although without any clear evidence, these preexisting aortic defects could play a role in etiopathogenesis of RTBAD. It should be considered the possibility that heavily calcified plaques at thoracic level, such as the one described in the first patient, may behave like a penetrating aortic ulcer and consequently require a more aggressive treatment. Although the few reported cases do not allow identifying specific pathogenetic mechanisms, our limited experience may suggest aortic malacia as a different risk factor for the development of RTBAD after EVAR. Regardless of the etiopathogenetic mechanism, once established, RTBAD is a devastating and a life-threatening complication: since aortic dilatation and rupture, visceral and spinal ischemia have been described.11,12,19 It is mandatory to promptly identify all potential risk factors to avoid their occurrence. In conclusion, from the data currently available in the literature, there are no predictive factors for this rare but life-threatening complication. For the first time, our experience highlights the possible etiologic role of preexisting lesions of the thoracic aorta. For this reason, even on the basis of a limited experience, the only possible strategy might be to study carefully the entire aorta before an EVAR procedure, and in the case of associated lesions, switch the indication to a surgical repair or carry out a more aggressive management, treating the defects of the thoracic aorta. REFERENCES 1. Moll FL, Powell JT, Fraedrich G, et al. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg 2011;41(Suppl 1):S1e58.
Case reports 127.e9
2. Setacci F, Sirignano P, de Donato G, et al. AAA with a challenging neck: early outcomes using the Endurant stent-graft system. Eur J Vasc Endovasc Surg 2012;44:274e9. 3. Paravastu SC, Jayarajasingam R, Cottam R, et al. Endovascular repair of abdominal aortic aneurysm. Cochrane Database Syst Rev 2014;CD004178. 4. Georgiadis GS, Georgakarakos EI, Antoniou GA, et al. Clinical outcomes after crossed-limb vs. conventional endograft configuration in endovascular AAA repair. J Endovasc Ther 2013;20:853e62. 5. Setacci F, Sirignano P, de Donato G, et al. Acute aortic dissection: natural history and classification. J Cardiovasc Surg (Torino) 2010;51:641e6. 6. Lu S, Lai H, Wang C, et al. Surgical treatment for retrograde type A aortic dissection after endovascular stent graft placement for type B dissection. Interact Cardiovasc Thorac Surg 2012;14:538e42. 7. Haesemeyer SW, Vedantham S, Braverman A. Renal artery stent placement complicated by development of a type B aortic dissection. Cardiovasc Intervent Radiol 2005;28: 98e101. 8. Cisek PL, McKittrick JE. Retrograde aortic dissection after bilateral iliac artery stenting: a case report and review of the literature. Ann Vasc Surg 1995;9:280e4. 9. Ochi M, Yamauchi S, Yajima T, et al. Aortic dissection extending from the left coronary artery during percutaneous coronary angioplasty. Ann Thorac Surg 1996;62:1180e2. 10. Beitzke A, Stein JI, Gamillscheg A, et al. Dissection of the descending aorta after balloon angioplasty of native coarctation. Pediatr Cardiol 1997;18:222e5. 11. Girardi LN, Bush HL Jr. Type B aortic dissection and thoracoabdominal aneurysm formation after endoluminal stent repair of abdominal aortic aneurysm. J Vasc Surg 1999;29:936e8. 12. Haulon S, Greenberg RK, Khwaja J, et al. Aortic dissection in the setting of an infrarenal endoprosthesis: a fatal combination. J Vasc Surg 2003;38:1121e4. 13. Iyer V, Rigby M, Vrabec G Sr. Type B aortic dissection after endovascular abdominal aortic aneurysm repair causing endograft collapse and severe malperfusion. J Vasc Surg 2009;50:413e6. 14. Tolenaar JL, van Keulen JW, Vonken EJ, et al. Fenestration of an iatrogenic aortic dissection after endovascular aneurysm repair. J Endovasc Ther 2011;18:256e60. 15. Pulli R, Fargion A, Pratesi G, et al. Aortic type B dissection with acute expansion of iliac artery aneurysm in previous endovascular repair with iliac branched graft. J Vasc Surg 2011;54:1788e91. 16. Khanbhai M, Ghosh J, Ashleigh R, et al. Type B aortic dissection after standard endovascular repair of abdominal aortic aneurysm. BMJ Case Rep 2013;9:2013. 17. Mamopoulos AT, Nowak T, Luther B. Retrograde ascending Stanford B aortic dissection complicating a routine infrarenal endovascular aortic reconstruction. J Vasc Surg 2013;58:208e11. 18. Yamamoto S, Hoshina K, Takazawa Y, et al. Aortic dissection occurring 18 months after successful endovascular repair in an anatomically difficult case of abdominal aortic aneurysm. Case Rep Vasc Med 2013;2013:412708. 19. Psacharopulo D, Ferrero E, Viazzo A, et al. Abdominal aortic endograft collapse due to false lumen radial force of an acute type B aortic dissection. Ann Vasc Surg. http://dx.doi.org/ 10.1016/j.avsg.2014.06.067. [Epub ahead of print].
