Interact CardioVasc Thorac Surg 2008;7:595-599. doi:10.1510/icvts.2008.175315
© 2008 European Association of Cardio-Thoracic Surgery
Institutional report - Vascular thoracic |
Endovascular repair of lesions involving the descending thoracic aorta. Mid-term morphological changes
Cherif Attiaa,
Fadi Farhata,*,
Loïc Bousselb,
Jacques Villarda,
Didier Revelb and
Philippe Douekb
a Department of Cardiovascular Surgery, Louis Pradel University Hospital, Lyon, France
b Department of Interventional Radiology, Louis Pradel University Hospital, Lyon, France
Received 20 January 2008;
received in revised form 10 April 2008;
accepted 14 April 2008
 Presented at the 57th International Congress of the European Society for Cardiovascular Surgery, Barcelona, Spain, April 24–27, 2008.
*Corresponding author. Department of Cardiovascular surgery, CREATIS, CNRS UMR 5515, INSERM U630 and U886, Hôpital Cardiovasculaire et Pneumologique Louis Pradel, Claude Bernard University, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France. Tel.: +(33) 4 72 35 75 29; fax: +(33) 4 72 35 75 32.
E-mail address: fadi.farhat{at}chu-lyon.fr (F. Farhat).
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Abstract
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Thoracic aortic lesions are often life-threatening conditions with significant morbidity and mortality after open surgical repair. If preliminary results suggest that endovascular therapy is an effective and advantageous treatment, long-term effectiveness remains questionable. We analysed 75 consecutive patients who underwent endovascular stent-grafting of lesions involving the descending thoracic aorta (32 emergent, 43 elective). Aortic pathologies were aneurysms (n=31), chronic (n=8) or complicated (n=6) type B dissections, penetrating ulcers (n=4) or aortic ruptures (n=26). Follow-up was performed using magnetic resonance angiography. In three cases, the procedure was stopped due to inappropriate arterial access calibre. The hospital mortality and morbidity were 8% and 12%, respectively. One patient of the chronic group presented a type I endoleak, treated by embolisation. After 1.5 months, the mortality and morbidity rates were 10.6% and 10.6%, respectively. The secondary endoleak rate was 16%. One patient died of aortic rupture 24 months after the procedure. In the aneurysm group, the regression of the aortic calibre was significant in 23 and stable in 28 patients. Thus, and despite encouraging early outcomes, mid-term results suggest a trend toward increased re-intervention and late complication rates in these high surgical risk patients. Therefore, continued surveillance of patients treated with stent-grafts is necessary.
Key Words: Thoracic aortic aneurysm; Aortic dissection; Endovascular treatment; Penetrating ulcer
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1. Introduction
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The natural history of degenerative aortic disease is progressive and may lead to dilatation, dissection or rupture. Aggressive medical treatment in parallel to a careful imaging follow-up contribute to improvement. However, medical therapy alone can only delay, but not avoid, aneurysm expansion and rupture: reported 5-year mortality is 16% for aneurysms <6 cm and 31% above this size [1]. Therefore, preventive surgical resection has long been considered as the only treatment, although associated with significant mortality and morbidity [2]. The endovascular techniques are revolutionizing the management of thoracic aortic disease, and enabling low-invasive repair even in high-risk patients unfit for open surgery. Compared with open surgery, stent-graft treatment was supposed to be associated with decreased peri-operative mortality rates and fewer complications [3, 4]. However, data on mid-term and long-term follow-up are limited.
The purpose of this study was to evaluate the mid-term outcome, complications and morphological changes in thoracic aortic lesions following an endovascular treatment.
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2. Patients and methods
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Between June 1999 and March 2007, 75 patients (61 male, mean age of 57 years), underwent endovascular thoracic aortic repair with the Talent and Valiant (Medtronic, World Medical Manufacturing Corp, Sunrise, FL) thoracic stent-grafts. Aortic lesions included 33 (44%) atherosclerotic aneurysms, 22 (29.3%) traumatic rupture of the isthmus, 14 (18.6%) type B dissections, 10 (13.3%) pseudo-aneurysms and 4 (5.3%) penetrating ulcers (Table 1).
The indications for acute lesions were traumatic rupture of the isthmus, type B dissections with malperfusion syndrome and ruptured aneurysms. The chronic lesion indications were aneurysms >50 mm and progressive penetrating ulcers of the descending thoracic aorta. Each case was evaluated by a multidisciplinary staff of surgeons, anaesthesiologists, and radiologists. Fifty-eight patients were classified as American Society of Anaesthesiologists (ASA) class III to IV. Previous cardiac or abdominal aortic surgery were reported in 9 (12%) and 5 (6.6%) patients, respectively. Mean aortic diameter for the aortic dissection and the aneurysms was 48.7 mm (range 30–90 mm).
Preoperative transposition of the left subclavian artery was necessary in two patients (2.6%) in order to obtain an effective proximal neck (minimum 20 mm) on the horizontal segment of the aortic arch. With respect to the usual classification of the thoracic descending aorta, we treated 29 (38.6%) type I lesions and 46 (61.3%) type II and III lesions.
2.1. Imaging evaluation
On admission, a large computed tomography angiography was systematically performed. Information on maximum aneurysm diameter or on dissection size, proximal and distal anatomic extension, and distance from the left subclavian artery were recorded.
After the procedure, magnetic resonance angiography (MRA) with gadolinium was performed before discharge and then 1, 3, 6, 12, 18 and 24 months and yearly thereafter. The imaging protocol included a series 1 min after injection to detect delayed endoleaks. The parameters evaluated were absence of flow in the aneurysm/false lumen, aneurysm dimension, morphology of the stent-graft, diameter and wall morphology of the proximal and distal necks.
2.2. Interventional endovascular procedure
All the patients were treated in a radio-surgical operating room, under general anaesthesia and controlled ventilation. A right radial artery catheterisation was performed to monitor systemic blood pressure. Anticoagulation during the operation was ensured by heparin bolus (5000 IU) at the beginning of the femoral catheterisation. Patients had a surgical access of the femoral (n=69), iliac arteries (n=3) and the abdominal aorta (n=3). Through a percutaneous left brachial artery access, a pigtail catheter (Cordis, Johnson and Johnson, Warren, NJ) was placed in the aortic arch to permit aortography before stent positioning. Through the femoral access, a rigid guide wire (Boston Scientific, Oakland, NJ) was placed up to the aortic root, over which the endovascular stent was inserted and advanced under fluoroscopic guidance. During the device expansion, systolic blood pressure was lowered to 50 mmHg using sodium nitroprussioate. The stent-graft diameter was chosen with respect to maximum diameter of the necks, with a 10–20% over-sizing. Several stent-grafts (2–4) were used in 11 patients, taking into account a 50% overlap. A final aortogram was performed to confirm the right positioning of the stent-graft and exclusion of the lesion.
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3. Results
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Immediate technical failure occurred in 3 (4%) patients due to inadequate calibre of the femoral or iliac arteries (two cases) or severe angulations of the aorta (one case). No surgical conversion and intra-operative mortality occurred. Covering of the left subclavian artery was necessary in two patients (2.66%) without ischaemic complications. An endoleak was visualised at the end of the procedure in eight patients. However, seven patients sealed spontaneously during follow-up. The distance between the left subclavian artery and the aneurysm was <20 mm in 20 patients (26.6%, Table 2).
3.1. Early outcome
Early mortality was observed in 6 (8%) patients. Post-procedure morbidity concerned 9 (12%) patients, including six common femoral or iliac arteries injuries, one transient cerebrovascular accident, one paraplegia, and one adjunctive endovascular treatment with coil embolization for endoleak resolution.
3.1.1. Acute lesions
All the complicated type B dissections (two bleeding and four malperfusion) had a satisfactory closure of the entry tear. Yet, one patient died of septic shock and intestinal ischaemia the day following the procedure. One patient presented paraplegia with partial resolution. Among the 22 patients with isthmus rupture associated with poly traumatic injuries, successful treatment was achieved in all cases. Three patients died of cardiac contusion, brain trauma and rupture of hepatic vessels, 12–24 h following the procedure. The eight patients with aneurysm rupture were all treated with satisfactory results. Two patients died in this group of septicaemia with aorto-oesophageal fistula and bilateral broncho-pneumonia, respectively two and four weeks after the procedure.
3.1.2. Chronic lesions
No early mortality was noted in this group. All the patients had a successful endovascular therapy. One patient presented a type I endoleak after the procedure and treated by coil embolisation.
3.2. Late outcome
Clinical and imaging follow-up was 31.5 months (range 3–60) and was completed for all patients. The global mortality concerned 14 patients (18.6%). The survival rate at 12 months was 84% and 36 months was 80% (Table 3).
3.2.1. Mortality
Eight patients (10.6%) died during the follow-up period including three patients of cardiac infarction and failure, two patients of cancer, two patients of septicaemia and one patient of aortic rupture 24 months after the procedure.
3.2.2. Secondary endoleaks
Late endoleaks occurred in 12 (16%) patients. In nine patients (aneurysms) and three patients (type B dissections), it was de novo type I endoleaks due to enlargement of the distal neck (n=3, Fig. 1), proximal endoleaks (n=6, Fig. 2), a type II endoleak due to reperfusion of the aneurysmal sac by an intercostal artery (n=1, Fig. 3) and type III endoleaks in two patients with stent-graft migration distally in the aortic wall (Fig. 4). All the six patients presenting with a proximal type I endoleak had a preimplantation proximal landing zone <20 mm. The three patients with a distal type I endoleak had a preimplantation lesion located in the distal third of an angulated thoracic aorta. Endovascular re-stenting was successful in eight patients (10.6%). One patient with a distal type I endoleak died from aortic rupture. Three patients with distal type I endoleaks are still being monitored.
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Fig. 1. (a) Para saggital section of MRA control at 24 months of a 73-year-old male treated for aneurysm of the middle part of the descending aorta. It shows a type I endoleak at the distal end of the graft. (b) Aortography of the same patient. It shows a dilatation and angulation of the aortic segment below the stent with migration of the stent responsible for re-permeability of the aneurysm.
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Fig. 2. (a) Para saggital section of an 80-year-old male of aortic scanner. It shows the absence of proximal neck of the aneurysm and the presence of a wall thrombosis. (b) Thirty-six months MRA control of the same patient. It shows a distal migration of the stent with a proximal type I endoleak.
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Fig. 3. Thirty-six months control of a 65-year-old patient treated for a penetrating ulcer of the distal part of the descending aorta. It shows repermeability of the ulcer after an excellent post-procedure result.
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Fig. 4. Para saggital section MRA control at 24 months of a 65-year-old patient treated for aortic aneurysm of the middle part of the descending aorta. It shows de novo extravasations of the radio marker below the stent with a punching into the aortic wall.
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3.2.3. Changes in aneurysm dimensions
In exclusion of the isthmus ruptures, the follow-up of the remaining 54 patients showed a significant regression (>5 mm) in 23 cases (21 aneurysms and 2 type B dissections, Fig. 5). There was a significant progression (>5 mm) in three patients (one aneurysm and 2 type B dissections). This group was associated with secondary type I endoleaks, 12–18 months after the procedure. Finally, there was a stability of the aneurysmal sac in 28 patients.
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Fig. 5. Aortic diameter regression using a Kalplan–Meier curve. The maximum of the aortic diameter regression is mainly noticed in the first six months.
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4. Discussion
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Endovascular treatment of descending thoracic aortic disease is a recent advance among interventional techniques. Its feasibility was first reported by Dake and colleagues [5] in 1994 using a homemade stent-graft. In 1997, commercially manufactured stent-grafts enabled increasing use in many centres [6]. Although safety and technical feasibility of this approach were soon established, as demonstrated by good short-term results for both elective and emergency settings [7], few mid and long-term follow-up data are available.
The first report of patients with complete 7-year follow-up was published by Alric and colleagues [8]. They found that for the repair of abdominal aortic aneurysms, despite acceptable short-term results, stent-grafts failed to protect patients from aneurysm-related death. Additionally, they reported a high rate of late complications, with 49% of the patients having endovascular leaks and 56.5% proximal stent migration.
The treatment of acute descending thoracic aortic lesions in an emergency setting remains a great challenge. Despite widespread use of standardized treatment protocols, high peri-operative morbidity and mortality limit the success of the conventional open surgical approach [9]. This is illustrated by Crawford and colleagues [10], who reported 44% of 30-day mortality for ruptured aneurysms of the descending thoracic aorta in patients with severe medical comorbidities. In addition, postoperative risk of paraplegia after emergent surgery was up to 25%. Fattori and colleagues [11] showed an in-hospital mortality of 5% in patients treated under emergency condition with stent-graft repair. In our study, the 30-day mortality for the emergency procedures was 8%, with one case of paraplegia (1.3%) in a patient treated for a type B dissection with a long thoracic aortic exclusion (150 mm).
If we can hypothesize that an endovascular approach is related to less perioperative mortality and morbidity in comparison to an open air strategy, the picture seems to be quite different in the treatment of elective lesions. Jacobs and colleagues [12] report a series of 73 consecutive thoraco-abdominal aortic surgical repairs with a total in-hospital mortality of 8% and an acceptable rate of morbidity (mostly renal). In our series, and after 31.5 months follow-up, the comparison to this conventional surgical approach renders the sky even cloudier. Twelve endoleaks (16%) were observed, 9 type I, 1 type II and 2 type III. These evolutions have various origins, such as the migration of the stent-grafts distally in a fragile aortic wall, a severely angulated aorta, a reperfusion of the aneurysmal sac through an intercostal artery or a significant dilatation of the distal neck of the aorta 12–24 months after the procedure. Eight of the 12 de novo endoleaks were treated by re-stenting, with an excellent immediate result. In parallel, we did not note any correspondence between the persistence or the recurrence of an endoleak and the evolution of the aortic diameter. Comparatively to the aortic rupture group (i.e. isthmus ruptures), we had neither a secondary evolution of the untreated segments above or below the implantation zone, nor a reperfusion around the stent by an intercostal artery. This statement seems simple because in an aneurysmal aorta, the anatomical lesions are not limited by some virtual frontier, and treating a dilated segment at one point of its evolution does not prevent the rest of the aorta from further dilatation.
Our findings show a trend toward increased procedure-related mortality and morbidity observable during follow-up. Similar mid-term results were reported by other groups after endovascular grafting for acute and elective lesions of the descending thoracic aorta. Doss and colleagues [13] showed that 6.2% of the patients had late ruptures (36 months) of thoracic aortic aneurysms with endovascular leak. Demers and colleagues [14] showed an overall 5-year mortality of 51% in patients undergoing endovascular repair with 69% in high-risk patients for surgery. They reported late rupture in 9% of the patients at five years and 20% at eight years. In our series, the late mortality rate was 11.5%. One patient had late rupture with evidence of endovascular leak. The endoleak rate during follow-up was 16%. Orend and colleagues [15] reported 17.6% overall mortality in 74 patients over a 6-year experience, considering that only one of the five late deaths was stent-graft related. In addition, the endovascular leak rate was 20.3%.
In conclusion, our study shows that the minimally invasive nature of endovascular interventions improves early outcome of patients treated for acute and elective lesions of the thoracic aorta, but late stent-graft-related complications such as endovascular leaks remain worrisome and impair postoperative quality of life. Thus, the validity of such an approach in patients eligible for open repair remains questionable.
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Abstract
1. Introduction
