Interact CardioVasc Thorac Surg 2008;7:1189-1190. doi:10.1510/icvts.2008.184051
© 2008 European Association of Cardio-Thoracic Surgery
Case report - Vascular thoracic |
Endovascular repair after stent elephant trunk procedure for extensive thoracic aortic aneurysm
Shang Dong Xua,*,
Zhan Ming Fanb,
Yu Lib and
Fang Jiong Huanga
a Division of Cardiac Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Vascular Diseases, Capital Medical University, Beijing, China
b Division of Radiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Vascular Diseases, Capital Medical University, Beijing, China
Received 19 May 2008;
received in revised form 26 August 2008;
accepted 27 August 2008
Corresponding author. Fax: +86-010-64456576.
E-mail address: xushangdong{at}vip.sina.com (S.D. Xu).
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Abstract
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Hybrid surgical-endovascular procedure was conducted in a 46-year-old male with extensive thoracic aortic aneurysm. Ascending aorta and arch replacement combined with stent elephant trunk implantation was performed first. An open stent-graft was implanted into the descending aorta. One month later, endovascular repair was conducted. Postoperative CTA showed total coverage of the descending aorta by stent-grafts and the descending aortic aneurysm was totally thrombo-excluded. Stent elephant trunk may be a better alternative to conventional elephant trunk in hybrid surgical-endovascular approaches in treatment of extensive thoracic aortic aneurysm.
Key Words: Thoracic aortic aneurysm; Elephant trunk procedure; Endovascular repair
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1. Introduction
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Repairing of the extensive thoracic aortic aneurysm by hybrid approaches (proximal elephant trunk procedure followed by endovascular repair of the descending aortic aneurysm) had achieved good results [1]. In recent years, stent elephant trunk emerged as an alternative to conventional elephant trunk [2]. Herein, endovascular repair after stent elephant trunk procedure is reported.
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2. Case report
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A 46-year-old male presented to our hospital with chronic back pain for four months. Extensive thoracic aortic aneurysm was confirmed by magnetic resonance angiography (Fig. 1). The diameter of the ascending aorta, arch and descending aorta was 5.2 cm, 3.4 cm and 7.0 mm, respectively. Hybrid approaches were scheduled. Ascending aorta and arch replacement combined with stent elephant trunk implantation was performed through median sternotomy. An open stent-graft ( 28 mmx100 mm, Cronus, Microport, Shanghai, China) was implanted into the descending aorta through the aortic arch under circulation arrest. The proximal end of the stent-graft was connected with a four-branched vascular graft ( 28 mm, Intervascular, La Ciotat, France). Postoperative course was uneventful. Computer tomography angiography (CTA) showed a wide opened stent elephant trunk and thrombus formed around the graft. One month later, endovascular repair was conducted under local anesthesia in the catheter lab. Left femoral artery was used as accessing artery. Three stent-grafts ( 28 mmx 170 mm, 28 mmx120 mm, 30 mmx170 mm, Grinkin, Beijing, China) were deployed one by one from distal to proximal. The endovascular repair procedure was described in detail in our previous paper [3]. The aorta just above the celiac trunk was used as distal landing zone. The stent elephant trunk served as the proximal landing zone by overlapping with the third stent-graft. Postoperative process was uneventful. Postoperative CTA showed total coverage of the descending aorta by stent-grafts and the descending aortic aneurysm was totally thrombo-excluded (Fig. 2).
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Fig. 2. Computer tomography angiography (CTA) of the patient. (Left) CTA after stent elephant trunk procedure. (Right) CTA after endovascular repair.
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3. Discussion
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Hybrid surgical-endovascular approaches have achieved better results than 2-stage surgical procedures in the treatment of an extensive thoracic aortic aneurysm [4]. Endovascular repair after stent elephant trunk procedure has not been reported in the literature yet. When hybrid approaches are used, the stent elephant trunk may have some advantages over conventional ones. First, the conventional elephant trunk is invisible under fluoroscopy unless some markers (like hemoclips or pacer wires) have been attached to it; while a stent elephant trunk can be seen very clearly under fluoroscopy. Second, since the stent elephant trunk is nearly straight, wide open and stable in the descending aorta, a guide wire can pass through it easily from distal end to proximal end and all the way up to the ascending aorta; while the conventional elephant trunk may be kinking, tortuous or compressed in the descending aorta, especially when the elephant trunk is relatively long (>10 cm). It is not easy to pass a guide wire into its distal end and through its whole length. In such case, a guide wire is needed to be threaded into its proximal end and through its whole length, then all the way down to the descending aorta, abdominal aorta, iliac artery and femoral artery. Finally, its tip is pulled out through arteriotomy in the femoral artery. This will make the whole procedure more complex. Third, a rigid, stable and wide opened stent elephant trunk serves as a better proximal landing zone than a soft and maybe tortuous conventional elephant trunk.
Since the whole length of the descending aorta would be covered by stent-grafts and no intercostal artery reconstruction would be conducted, paralysis was a major concern for this patient before endovascular repair. During the procedure, aortography did not show any patent intercostal artery. So we didn't hesitate to cover the whole length of the descending aorta with stent-grafts. Occlusion of the intercostal arteries may be due to the artherosclerosis of the aneurysm wall.
The stent elephant trunk may be a better alternative to conventional elephant trunk in hybrid surgical-endovascular approaches in the treatment of an extensive thoracic aortic aneurysm.
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References
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- Greenberg RK, Haddad F, Svensson L, O'Neill S, Walker E, Lyden SP, Clair D, Lytle B. Hybrid approaches to thoracic aortic aneurysms: the role of endovascular elephant trunk completion. Circulation 2005;112:2619–2626.[Abstract/Free Full Text]
- Kato M, Ohnishi K, Kaneko M, Ueda T, Kishi D, Mizushima T, Matsuda H. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation 1996;94(Suppl_II):II188–II193.[Medline]
- Xu SD, Huang FJ, Yang JF, Li ZZ, Wang XY, Zhang ZG, Du JH. Endovascular repair of acute type B aortic dissection: early and mid-term results. J Vasc Surg 2006;43:1090–1095.[CrossRef][Medline]
- Estrera AL, Miller CC 3rd, Porat EE, Huynh TT, Winnerkvist AN, Safi HJ. Staged repair of extensive aortic aneurysms. Ann Thorac Surg 2002;74:S1803–S1805.[Abstract/Free Full Text]
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Abstract
1. Introduction