Interact CardioVasc Thorac Surg 2009;8:359-361. doi:10.1510/icvts.2008.195164
© 2009 European Association of Cardio-Thoracic Surgery
Proposal for bail-out procedures - Aortic and aneurysmal |
Endovascular correction of a distal re-entry in an abdominal aorta dissection
Marcio Da Rochaa,
Salvador Mirandaa,
Marta Burrellb and
Vincente A. Riambaua,*
a Division of Vascular Surgery, Thorax Institute, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain
b Division of Interventional Radiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
Received 24 September 2008;
received in revised form 18 November 2008;
accepted 19 November 2008
 Presented at the 57th International Congress of the European Society for Cardiovascular Surgery, Barcelona, Spain, April 24–27, 2008.
*Corresponding author. Tel.: +34 932275515; fax: +34 932275749.
E-mail address: vriambau{at}clinic.ub.es (V.A. Riambau).
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Abstract
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The re-entries are still a problem for the endovascular treatment of aortic dissections. A 60-year-old man was treated for an abdominal aortic dissection using aortic monoiliac endograft until the left iliac external artery and a femoro-femoral bypass with occlusion of the right common iliac artery and the left hypogastric artery. In his third year of follow-up, a re-entry tear in the right hypogastric ostium was diagnosed with pressurization of the aortic and common iliac aneurysmatic sac, that required correction. A self-expandable covered stent in a ‘U’ configuration was implanted, connecting the right external and internal iliac arteries, with preservation of the pelvic circulation, and exclusion of the aneurysmatic sac. In conclusion, the use of a flexible stent graft is a safe alternative, and simplifies some procedures in complex circumstances.
Key Words: Dissection; Abdominal aorta; Re-entry tear; Covered stent; Hypogastric artery; Pelvic circulation
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1. Introduction
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The most important advance in aortic surgery in the last decades was the endovascular intervention. An area of such attention is the endovascular approach in aortic dissection [1]. However, the re-entries are frequently complicated for this surgery [2, 3]. Sometimes it is necessary to use another procedure for correction, which generally is more complex than the first intervention and adds some risks. Another challenge, in some circumstances, is the preservation of the pelvic circulation, because sometimes it is necessary to occlude the hypogastric artery [4].
This work reports the treatment of a re-entry, which originated in the sole permeable hypogastric artery, in which it was necessary to preserve the pelvic circulation, using a ‘U-stent graft’, in a patient submitted previously to an endovascular correction of an abdominal infrarenal aortic dissection.
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2. Report
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A 60-year-old man presented with an abdominal infrarenal aortic dissection. His medical history was notable for hypertension and past use of tobacco. The principal entry tears between the true and the false lumens were in the distal aorta and in the left hypogastric artery. He underwent correction of the dissection because of persistent abdominal pain and enlargement of the false lumen. The endovascular procedure consisted of a Zenith (Cook, Inc, Bloomington, IN) aorto monoiliac graft, until the left iliac external artery. The right common iliac artery and the left hypogastric artery were occluded. A femoro-femoral bypass was performed. In his three-year follow-up, in the CT angiography one re-entry tear in the right hypogastric ostium with enlargement of the aortic and common iliac aneurysmatic sac was identified (Fig. 1). The pressurized right common iliac artery had 37 mm of diameter and the terminal aorta 59 mm, which put the aneurysmatic sac in risk of rupture. The patient clearly expressed the wish of keeping his sexual activity.
The therapeutic plan included a strategy to preserve the right hypogastric artery and pelvic circulation. He was submitted to the deployment of a reverse U self-expandable covered stent of 11 mm in diameter (Emovahn – W.L. Gore & Associates, Flagstaff, AZ, USA) in the right iliac external artery to the internal iliac, in order to preserve his pelvic circulation. There was exclusion of the communication between the true and the false lumens, without endoleak or complications. He was discharged within 24 h. The one-month control CT-scan was performed, and there was exclusion of the false lumen, without new re-entries (Fig. 2).
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3. Discussion
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The Achilles' heel of the aortic dissection are the re-entries. It is the most frequently related complication and cause of return to the hospital in this kind of patient. The fear is sac expansion with the consequent risk of rupture and death, or the necessity of reintervention.
The treatment of the re-entries is not always necessary. The most reasonable is a selective treatment. The intervention is indicated when there is an enlargement of the aneurysmatic sac. In the case reported here, there was pressurization and enlargement of the aneurysmatic sac of the common iliac artery and distal aorta, which put this patient in direct risk of rupture. This case was a challenging one because of the necessity of preservation of the right hypogastric artery. The communication with the false lumen originated in this artery, and the left hypogastric artery had been occluded previously.
The preservation of the pelvic circulation is necessary because it is known that its interruption may have some serious consequences. The buttock claudicating was reported in up to 40% of the patients with hypogastric interruption, and sexual impotence in up to 20%. Other complications are bowel ischemia, paraplegia and glutei compartment syndrome [5]. An attempt to prevent the glutei claudication, in the endovascular treatment of the abdominal aortic aneurysm, is to obstruct the hypogastric artery in its ostium, and not in its branches. Cynamon et al. [6] reported buttock claudicating in 10% of the patients with proximal obstruction and in 55% of patients with obstruction of the hypogastric bifurcation. These maneuvers are important to prevent such complications, as the bowel infarct has a mortality rate of almost 40% [7].
There are a variety of alternatives to prevent the obstruction of the hypogastric arteries and they were developed with the objective of avoiding its complications.
In this case, as the patient had a femoro-femoral bypass of the left to the right, and the right common iliac artery was occluded previously, it was more reasonable and creative to use a reverse U-stent graft. In other words, it was more interesting for the revascularization of the iliac internal by the iliac external. The therapeutic option of using a ‘U-stent graft’ was described by Kotsis et al. [8], but it was performed from the common femoral to the external iliac artery, to treat a bilateral common iliac artery aneurysm, keeping flow to the hypogastric artery. In our case we used the U-stent graft from the right external iliac artery to the hypogastric artery. As far as we know, this is the first description of utilization of this technique in order to exclude a false lumen, in a case of a distal re-entry, with preservation of the hypogastric artery flow. This procedure was a safe alternative to preserve the hypogastric flow and exclude the aneurysmatic sac. Re-entry is an important late complication of the aortic dissection treatment. In this case, it was used as a safe endovascular option to treat a specific problem of this surgical modality. It avoided an open procedure and kept the pelvic circulation, with a good result.
Other options to preserve the hypogastric artery in the treatment of aortic aneurysms are the bifurcated iliac side-branch device [9], hypogastric artery bypass [10] and the aorto-monoiliac endovascular approach with a femora-femoral crossover.
In conclusion, the use of a flexible stent graft is a safe alternative in selected cases, and may simplify some procedures in complex circumstances.
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References
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Abstract
1. Introduction
