Annals of Vascular Surgery
Volume 22, Issue 2 , Pages 168-172, March 2008

Endovascular Repair of a Ruptured Descending Thoracic Aortic Aneurysm in a Patient with an Ascending Aortic Aneurysm: Hybrid Open Arch Reconstruction with Simultaneous Thoracic Stent-Graft Deployment within Elephant Trunk

  • Ahmed M. Abou-Zamzam Jr.

      Affiliations

    • Division of Vascular Surgery, Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
    • Corresponding Author InformationCorrespondence to: A. M. Abou-Zamzam, Jr., 11175 Campus Street, Suite 21123, Loma Linda, CA 92354, USA
    • ,
  • Wayne Zhang

      Affiliations

    • Division of Vascular Surgery, Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
    • ,
  • Nan Wang

      Affiliations

    • Division of Cardiothoracic Surgery, Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
    • ,
  • Anees Razzouk

      Affiliations

    • Division of Cardiothoracic Surgery, Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA

Article Outline

Endovascular repair of the thoracic aorta is now widely practiced. The extension of this technique to emergent settings is in evolution. Pathology of the ascending and transverse aortic arch may preclude thoracic aortic stent grafting due to the lack of a proximal seal zone. Several hybrid open/endovascular approaches have been described. We recently encountered the difficult case of a contained rupture of a 6.8 cm descending thoracic aortic aneurysm in a 60-year-old patient with aneurysmal degeneration of the ascending and transverse aortic arch. This patient was treated with a hybrid approach of open ascending and transverse arch reconstruction along with simultaneous stent-graft repair of the descending thoracic aorta. The open repair established an excellent proximal landing zone by use of the “elephant trunk” technique. This technique also allowed direct suture fixation of the stent graft to the arch graft to prevent stent-graft migration. This hybrid surgical approach was successful and avoided the cumulative morbidity that a left thoracoabdominal approach would have added to the sternotomy. Further creative uses of these hybrid techniques will undoubtedly serve a larger role in the treatment of thoracic aortic pathology.

 

The treatment of aortic aneurysms has evolved rapidly over the past several years since the introduction of aortic stent grafts. The use of stent grafts has recently expanded to the thoracic aorta with the approval of a commercially available thoracic stent graft (TAG; W. L. Gore, Flagstaff, AZ). The current instructions for use limit the device to the treatment of descending thoracic aortic aneurysms with appropriate proximal and distal landing zones. Many patients may have a compromised proximal landing zone due to simultaneous aneurysms of the ascending and transverse arch.1 “Hybrid” approaches have been described in which an open reconstruction of the proximal arch is performed to provide an adequate proximal landing zone for subsequent thoracic stent grafting.2, 3, 4, 5, 6

Endovascular repair of thoracic aortic pathology offers a considerable decrease in operative morbidity and mortality in the elective setting and is now being practiced in emergent settings.7, 8, 9, 10 We recently encountered a patient with an emergent indication for repair of a ruptured descending thoracic aneurysm. This patient had an aneurysm of the ascending aorta without an adequate proximal landing site for a TAG device. This patient was approached through a hybrid treatment with open aortic arch reconstruction and simultaneous deployment of a thoracic stent graft in an elephant trunk. This is the first reported case of such a hybrid procedure performed in an emergent setting using a commercially available device.

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Case Report 

A 60-year-old male presented to the cardiothoracic service with a recent diagnosis of aneurysms of the ascending, transverse, and descending thoracic aorta. The patient's medical history was significant for past hypertension, chronic obstructive pulmonary disease, and obesity and for current tobacco use. The patient had a surgical history significant for a left carotid–subclavian bypass for left arm ischemia. Computed tomography (CT) scanning demonstrated an aneurysm of the descending thoracic aorta measuring 5.7 cm in maximal diameter and an aneurysm of the ascending aorta measuring 5.2 cm (Fig. 1). A decision was made to repair the ascending arch aneurysm on an elective basis, followed by staged repair of the descending thoracic aorta.

The patient was lost to follow-up and returned 3 months later with chest pain. A repeat chest CT scan demonstrated a contained rupture of the descending thoracic aneurysm, which had now expanded to 6.8 cm (Fig. 2). Evaluation of the anatomy of the aneurysm demonstrated a proximal landing zone less than 1.5 cm in length with a large, reversed funnel configuration, making the patient a suboptimal candidate for placement of the TAG device. Open thoracic repair was considered very high risk due to the patient's poor pulmonary status. The patient was taken to the operating room for a combined open repair of the ascending and transverse aortic aneurysm with the elephant trunk technique, which would allow simultaneous treatment of the ruptured descending thoracic aneurysm with a TAG device.

In the standard manner, the patient underwent ascending and transverse arch replacement under hypothermic circulatory arrest. Open exposure of the left common femoral artery and percutaneous access to the right common femoral artery was performed prior to circulatory arrest. The patient underwent replacement of the ascending and transverse arch with a 30 mm woven polyester graft. A 20 x 10 mm bifurcated graft was brought off the ascending graft, one limb was sewn end–end to the innominate artery, and the second limb was sewn to the left common carotid artery. An elephant trunk 10 cm in length was fashioned to the distal transverse arch to complete the reconstruction (Fig. 3A, B). When placing the elephant trunk, a guidewire from the left femoral artery was passed through a small hole in the ascending aortic graft for later manipulation. The bypass time was 160 min, and the circulatory arrest time was 27 min. Cerebral perfusion during circulatory arrest was performed via right axillary artery cannulation.

Once the patient was rewarmed and off cardiopulmonary bypass, repair of the descending thoracic aneurysm was performed. Retrograde delivery of the TAG device was possible after securing a long, stiff guidewire from the left common femoral artery, through the elephant trunk and into the arch graft. The thoracic rupture was treated with a 37 mm x 20 cm proximal and a 40 mm x 20 cm distal TAG device (Fig. 3C). Completion angiography demonstrated no endoleak with successful exclusion of the aneurysm and an appropriately reconstructed arch (Fig. 4). In order to prevent migration of the TAG device, the TAG was secured within the polyester graft using interrupted, nonabsorbable, monofilament sutures. These sutures were placed from outside both grafts along the anterior two-thirds of the proximal TAG–polyester graft overlap.

The patient's postoperative course was complicated by a small pulmonary embolus, which required anticoagulation. The patient was discharged on postoperative day 13. A CT scan prior to discharge demonstrated successful arch reconstruction and aneurysm exclusion. The patient returned at 3 months, and a follow-up CT scan demonstrated continued aneurysm exclusion with no evidence of endoleak (Fig. 5). The patient did well for several months but died due to a sudden neurologic event, suspected of being bacterial meningitis. A CT scan performed during his final hospitalization demonstrated no evidence of infection of the grafts or endoleaks.

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Discussion 

The treatment of thoracic aortic pathology is in evolution. Similar to the evolution of infrarenal repair, the conversion from open to endovascular repair has several significant advantages in morbidity and mortality.7, 8 Anatomic constraints are common and preclude thoracic stent grafting in a large percentage of patients.1 Hybrid approaches are now expanding the application of stent grafts so that it is not a question of “open or endovascular” but “open and endovascular.” Hybrid approaches seeking to provide proximal and/or distal landing zones for treating complex aneurysms have been applied for arch aneurysms as well as thoracoabdominal aneurysms.11, 12

Combined ascending and descending aortic arch pathology has traditionally been treated with staged operations. The concept of allowing a proximal landing zone for repair of descending aortic aneurysms has long been associated with the use of the “elephant trunk.” This open technique can clearly provide a proximal landing zone for stent grafts in the descending thoracic aorta just as it provides a zone for suturing an aortic prosthesis.3, 4, 5, 6, 13 The benefits of a single-stage operation include avoidance of interval rupture as well as the options of either antegrade and retrograde stent-graft deployment. Endovascular repair of the descending thoracic aorta also avoids the morbidity of a thoracoabdominal incision. This single-stage operation is the natural evolution of the two-stage repair. The second-stage endovascular repair in a prior elephant trunk was first described by Fann et al. in 19956 and has been reported by several others.3, 5 Many cases have employed a homemade thoracic endograft.5, 6, 14 Now the Food and Drug Administration–approved TAG device can be employed and is widely available.

The current case is quite similar to a recent report by Azizzadeh et al.,2 though with important differences. The current case highlights the ability to perform this operation in the setting of a contained rupture. The retrograde approach is helpful and allows controlled delivery of the stent graft with through-and-through wire access to avoid any misdeployments or distal aortic perforations.14 The securing of the stent graft within the arch graft with direct suturing also should remove the potential for late distal migration of the stent graft.

A technical point to make is trialing the stent graft within the polyester graft prior to implantation. In this case, a 37 mm device was deployed within a 30 mm woven polyester graft. This oversizing was felt to be important as the direct interaction with the 34 mm device appeared less secure. Also, with the potential for late dilation of the polyester graft, this oversizing may prove critical to long-term performance.

The simultaneous repair of an ascending and transverse arch aneurysm along with a contained rupture of a descending thoracic aortic aneurysm was accomplished with a hybrid open and endovascular technique. Open arch repair with an elephant trunk provides a proximal landing zone for a TAG thoracic stent graft within the elephant trunk. This case was accomplished with minimal morbidity and avoided the thoracic morbidity in a patient with severe pulmonary disease. A single-stage operation avoids the potential for interval aneurysm rupture and provides ever-widening options for the treatment of aortic pathologies.

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References 

  1. Jackson BM, Carpenter JP, Fairman RM, et al. Anatomic exclusion from endovascular repair of thoracic aortic aneurysm. J Vasc Surg. 2007;45:662–666
  2. Azizzadeh A, Estrera AL, Porat EE, Madsen KR, Safi HJ. The hybrid elephant trunk procedure: a single-stage repair of an ascending, arch, and descending thoracic aortic aneurysm. J Vasc Surg. 2006;44:404–407
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 Presented at the Twenty-fifth Annual Meeting of the Southern California Vascular Surgery Society, Coronado, CA, May 5th, 2007.

PII: S0890-5096(07)00302-0

doi:10.1016/j.avsg.2007.09.001

Annals of Vascular Surgery
Volume 22, Issue 2 , Pages 168-172, March 2008

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