Interact CardioVasc Thorac Surg 2009;8:488-490. doi:10.1510/icvts.2008.195230
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Aortic and aneurysmal |
Extra-anatomic bypass for recurrent abdominal aortic and renal in-stent stenoses following radiotherapy for neuroblastoma
Maximilian Luehr*,
Matthias Siepe,
Friedhelm Beyersdorf and
Christian Schlensak
Department of Cardiovascular Surgery, University Medical Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
Received 30 September 2008;
received in revised form 5 December 2008;
accepted 9 December 2008
 Presented at the Aortic Symposium 2008, New York, NY, May 08–09, 2008.
*Corresponding author. Tel.: +49 (0)761 270 8888; fax: +49 (0)761 270 2788.
E-mail address: mail{at}dr-luehr.net (M. Luehr).
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Abstract
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We describe the case of an 11-year-old girl with an abdominal neuroblastoma which was operated and intraoperatively irradiated nine years ago. After six years, she developed stenoses of the infrarenal abdominal aorta and both renal arteries. Initial treatment of the stenosed vessels comprised endovascular balloon dilatations and repeated stent-graft implantations, including drug eluting stents. However, severe in-stent stenoses occurred during follow-up and the girl developed acute renal failure. Open surgery was performed with two extra-anatomic bypasses, a thoracic-to-abdominal aortic bypass and a left iliac-to-renal bypass, on an urgent basis. The postoperative course was uneventful and the patient was discharged home two weeks after the operation with full recovery of renal function. We conclude that endovascular stent-graft placement in children can only be a palliative treatment due to outgrowing of the stent-graft and the potential risk of re-stenosis, especially after a history of irradiation. Vascular surgery with placement of extra-anatomic bypasses will provide a definite treatment.
Key Words: Aorta/aortic; Renal; Stenosis; Radiation therapy; Neuroendocrine tumor
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1. Introduction
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Irradiation induced severe stenoses of the renal arteries and/or the abdominal aorta are rare complications that may occur shortly or even several years after radiotherapy for neuroblastoma.
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2. Case report
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We report a case of an 11-year-old girl (146 cm, 36 kg) with severe stenosis of the suprarenal abdominal aorta, additional in-stent stenoses of both renal arteries and the infrarenal abdominal aorta, chronic occlusion of the celiac trunk and secondary arterial hypertension, nine years after the operation and intraoperative irradiation of an abdominal neuroblastoma.
Initially, the stenoses of both renal arteries as well as the infrarenal abdominal aorta were treated with balloon dilatations. At the age of 8 years (130 cm, 30 kg) in 2005, the abdominal aorta was stented with a S.M.A.R.T. Control Stent (Cordis Corporation, NJ, USA) just below the superior mesenteric artery. At the same time, the right renal artery was additionally stented with a Palmaz Genesis Stent (Cordis Corporation, NJ, USA) while the left renal artery was stented with a Multi-Link Ultra Coronary Stent (Abbott Laboratories, IL, USA). During follow-up, in-stent stenoses (80–90%) of both renal arteries occurred which were treated both by additional stent-in-stent implantation of a drug eluting stent (Taxus, Boston Scientific, MA, USA). A recurrent in-stent stenosis (75%) of the right renal artery was treated by balloon dilatation. In 2007, elective surgery was planned but had to be rescheduled due to acute gastroenteritis.
At the time of referral to our institution, the patient already suffered from right renal insufficiency, intermitted claudication and constantly high creatinine levels which already had required two times of dialysis. The present findings of severe aortic stenosis (Ø 5 mm) as well as renal in-stent stenoses and the imminent danger of renal failure made surgical treatment necessary (Fig. 1).
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Fig. 1. Preoperative 3D-MRI of the thoracoabdominal aorta shows right renal in-stent stenosis (right) and the stenosed suprarenal abdominal aortic segment.
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An operation was planned to bypass the stenosed abdominal aortic segment and to revascularize the renal arteries. Revascularization of the celiac trunk was deemed unnecessary due to occurrence of a prominent inferior mesenteric artery and an anastomosis of Riolan. A retroperitoneal approach was performed via a left-sided incision. The distal thoracic and the abdominal aorta down to the left common iliac artery were dissected in the usual fashion. A 16-mm Dacron prosthesis (Vascutek Terumo, Renfrewshire, Scotland) was used for the thoracic-to-abdominal aortic bypass. The prosthesis was selected liberal in length and arranged in an arched position to allow elongation during growth. The native abdominal aorta with the previously implanted endovascular stent-graft remained in place. Afterwards, the left renal artery was dissected and the occluded renal stent-grafts were removed. A left iliac-to-renal bypass was then performed using an endoscopically harvested saphenous vein. Dissection of the right renal artery and placement of an extra-anatomic bypass was impossible due to severe adhesions around the vessel.
Direct postoperative course was uneventful. Ultrasound showed unobstructed blood flow to the left renal artery and left renal function showed progressive improvement. Intraarterial digital subtraction angiography (DSA) showed excellent perfusion of the bypasses (Fig. 2). Four days later, the patient developed symptoms of a mild paralytic ileus which was treated medically. The patient was discharged home two weeks after the operation. Left renal function and creatinine levels normalized within the first weeks after discharge. Presently, after fourteen months of follow-up, the patient is doing well with no evidence of clinical problems or claudication.
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Fig. 2. Postoperative intra-arterial DSA shows excellent perfusion of the thoracic-to-abdominal (left) and the iliac-to-renal bypass (right).
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3. Discussion
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Treatment of advanced neuroblastoma is a highly interdisciplinary approach which combines chemotherapy, surgery, and subsequent radiotherapy. Even though neuroblastomas are chemosensitive allowing down-staging with subsequent radical surgery, radiotherapy might become necessary in cases in which chemotherapy is not successful or complete tumor extirpation cannot be achieved. Today we know that small arteries are affected the most by irradiation, followed by medium sized and large arteries, while veins seem to be less affected than their arterial counterparts [1]. Therefore, intraoperative radiotherapy is used to apply a single large radiation dose to a malignant mass during surgery to spare normal tissue from irradiation but vessel stenoses are still reported nowadays [2, 3]. However, abdominal aortic stenosis is a rare complication that may occur several years after radiotherapy for neuroblastoma and only few reports are available which describe occurrence of this entity [4, 5].
Initial diagnosis of neuroblastoma is usually made during early childhood and the majority of patients are just at the beginning of their growth period. If irradiation induced stenoses of the aorta and large arteries do occur, open bypass surgery might be inappropriate due to small vessel calibers and endovascular interventions, such as balloon dilatation and/or the implantation of stent-grafts, become the preferred treatment [6]. However, endovascular stent-grafting may inhibit growth of the non-atherosclerotic normal aorta and can lead to intimal hyperplasia and focal fibrosis in the inner media part adjacent to the stent [7]. Therefore, endovascular interventions at that time can only be palliative treatments before re-stenoses occur.
In this case, the patient was also treated several times endovascularly for aortic and renal artery stenoses before referral to our institution. Beside several balloon dilatations, the severely stenosed infrarenal aorta needed endovascular stent-grafting while both renal arteries even needed placement of two endovascular stent-grafts. Regardless, further aortic stenosis as well as recurrent in-stent stenoses occurred, finally resulting in right renal insufficiency and secondary arterial hypertension. At that time (age 11), no further interventional treatment was possible anymore and, therefore, definite surgery was strongly required. Fortunately, the patient's constitution (thoracic aortic Ø 15 mm) allowed to perform open bypass surgery with a 16-mm Dacron prosthesis which has an adequate size and length to ensure perfusion of the lower body and will allow further growth of the patient. Nevertheless, close follow-up is recommended to preclude further aortic stenosis and/or stenosis of the iliac-to-renal bypass.
We conclude that in cases of severe irradiation induced stenosis of the aorta and large arteries in children, endovascular interventions can only be palliative treatments due to outgrowing of the stent-grafts and the potential risk of re-stenosis. Vascular surgery with placement of extra-anatomic bypasses will provide a definite treatment.
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References
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Abstract
1. Introduction
