HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wong, C.H. Articles by Hasan, A. Search for Related Content PubMed PubMed Citation Articles by Wong, C.H. Articles by Hasan, A. Related Collections Great vessels

Eur J Cardiothorac Surg 2001;19:528-530
© 2001 Elsevier Science NL

Case report

A dual strategic approach to mega-aortic aneurysms

^a Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
^b Department of Vascular Surgery, Freeman Hospital, Newcastle upon Tyne, UK
^c Department of Radiology, Freeman Hospital, Newcastle upon Tyne, UK

Received 22 November 2000; received in revised form 28 January 2001; accepted 4 February 2001.

Corresponding author. Tel.: +44-705-060-9664; fax: +44-870-126-9994
e-mail: wongch{at}postmaster.co.uk

	Abstract

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion References

 
Staged resection of mega-aortas with Borst's two-stage elephant trunk (ETK) is the gold standard but has a higher mortality and morbidity compared to single-segment repair. We report the first case of combined surgical and covered-stent approach in Europe. Location and dilatation of the proximal landing zone accounts for the majority of failures in covered-stenting but an ETK is stable, easy to localise and gives an excellent seal. In high-risk cases where surgical resection is not offered, stenting is an option. The lack of a thoracotomy is an advantage in often-frail patients recovering from stage-I and shortens ITU-stay. Therefore, a combined approach is an acceptable alternative in selected individuals.

Key Words: Elephant trunk • Mega aortic aneurysm • Thoracic aortic stenting

	1. Introduction

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion References

 
Patients with generalised dilation of their aorta or Mega-aortic syndrome have a significantly higher surgical risk of mortality and neurological injury compared to resection of simple thoracic aneurysms.

In 1983, Borst described replacing the ascending aorta and the arch with an elephant trunk (ETK) through a median sternotomy [1]. This is later followed by staged replacement of the thoraco-abdominal aneurysm through a left thoracotomy.

The ETK simplifies the control of the aneurysm in the second stage and allows resection without the use cardiopulmonary bypass. However, in the last two decades, covered-stents for the descending aorta has become routine and widely available. With significant numbers now being performed in certain centres [2]. Although certain questions remain concerning the durability of covered-stents and their placement, they have found a role.

This report aims to illustrate that management of ‘Mega aortas’ using a combination of surgery and stenting has several advantages and may become the treatment of choice in future.

	2. Clinical summary

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion References

 
A 70-year-old woman presented with anterior chest pains. Myocardial infarction was excluded and a subsequent CT scan showed aortic enlargement from the ascending to the abdominal aorta. Her operative risk was considered high and thus only hypertension control and followed-up was offered.

However, 2 years later she developed hoarseness and left vocal cord palsy from recurrent laryngeal nerve compression was confirmed. Repeat CT scans had showed that the mega-aorta had grown in the intervening period and was now approximately 7 cm in the ascending aorta increasing in size to 8.2 cm in the descending aorta (Fig. 1) . Given her new symptoms and the rapid aneurysmal enlargement, surgery was offered. Careful weighing of the risks suggested that a combination of stage-I ETK replacement and descending covered-stenting was optimal.

View larger version (179K): [in this window] [in a new window]   Fig. 1. CT mapping scan demonstrating generalised dilatation of the thoracic aorta down to the diaphragm.

The aortic arch was replaced with a 34 mm Gelseal conduit by invaginating the graft and inserting it into the descending aorta. The anastomosis to the was completed using 4/0 prolene. The proximal portion of the graft was retrieved and the head vessels reimplanted on a button of aortic tissue.

After haemostasis, she was weaned off bypass on small doses of inotropes. Total cardiopulmonary bypass time was 271 min with myocardial ischaemic time of 132 min and total body hypothermic circulatory arrest and selective cerebral perfusion time of 67 min.

She required ventilation for 36 h after which she was returned to the ward with no transient or permanent neurological deficits and discharged 12 days later with elective admission in 3 months for stenting.

However, she developed severe back pain and collapsed 2 months later. She was admitted and found to have a contained rupture (10.2 cm) of the descending aortic aneurysm. Thus she underwent emergent cover-stenting to exclude the leak. In an angiography suite, the common iliac artery was exposed because the common femoral artery was small. A series of three (2x15 mm, 1x20 cm diameter) covered-stents (Gore Aortic Excluder, USA) was inserted and using fluoroscopic and trans-oesophageal echocardiographic guidance, they were positioned and deployed to allow a margin of overlap. At the end of the procedure the aneurysm was fully excluded and good flow into the coeliac axis and renal arteries was confirmed (Fig. 2) .

View larger version (196K): [in this window] [in a new window]   Fig. 2. Aortogram demonstrating the position of the covered-stents and exclusion of the descending thoracic aneurysm.

	3. Discussion

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion References

 
Crawford reported that patients with aneurysms of the ascending aorta and arch or descending thoracic aorta have or will develop distal aneurysmal dilatation in over 70% of cases [3]. Those patients with ‘mega-aortas’ have a significantly higher mortality rate whether or not the distal disease is resected even after replacement of the ascending and aortic arch aneurysms [3].

In 1983, Borst described the staged ‘elephant trunk’ technique for surgical resection of mega-aortic aneurysms [1] which simplified the task of controlling the descending aortic aneurysm, even allowing resection without bypass. However each stage of the elephant trunk the same risk of mortality and permanent neurological injury as a single-segment repair [4,5].

Covered-stents have undergone rapid development in the last 2 decades. Recently, Grabenwonger reported 21 patients with descending aortic aneurysm undergoing covered-stenting with a mortality rate of 9.5% (2/21) and no paraplegia [2].

These numbers are small compared to the experience of 1250 cases reported by Coselli with a mortality and paraplegia rate of 4.9 and 5% respectively. But the results are encouraging given that the stent group was deemed unsuitable for surgical repair.

Only one case has been reported from an American institution of cover-stenting of mega-aortic aneurysms after stage-I elephant trunk replacement with a custom made stent [6]. Currently, covered-stents several commercially available and are extremely compact and deploy more reliably.

However there are many issues still to be resolved definition of the landing zone is critical to the short and long-term durability. ‘Endo-leak’ has been reported in up to 50% of abdominal aortic aneurysm stents [7]. And although the majority decreases in size after stenting, there are reports of continuing aneurysmal growth with or without endo-leak [8,9]. Migration of the stent is another problem with up to 45% of cases showing movement of the stent after a mean follow up of 29 months [10]. This was attributed, in part, to proximal dilation of the aneurysm.

These problems should not arise with stenting of elephant trunks, which provides a well definite landing zone, a stable diameter and excellent seal. The advantages of stenting as the second stage are obvious. There is no need for a large thoracotomy with likelihood of faster recovery and shorter ITU stay and in frail patients not suitable for surgery, this may be the only potential option.

However, stenting should not be carried out by the inexperienced and must be performed in collaboration with cardiothoracic and vascular surgeons.

	References

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion References

 

1. Borst H.G., Walterbusch G., Schaps D. Extensive aortic replacement using ‘elephant trunk’ prosthesis. Thorac Cardiovasc Surg 1983;31:37-40.[Medline]
2. Grabenwoger M., Hutschala D., Ehrlich M.P., Cartes-Zumelzu F., Thurnher S., Lammer J., Wolner E., Havel M. Thoracic aortic aneurysms: treatment with endovascular self-expandable stent grafts. Ann Thorac Surg 2000;69:441-445.[Abstract/Free Full Text]
3. Crawford E.S., Coselli J.S., Svensson L.G., Safi H.J., Hess K.R. Diffuse aneurysmal disease (chronic aortic dissection, Marfan, and mega aorta syndromes) and multiple aneurysm. Treatment by subtotal and total aortic replacement emphasizing the elephant trunk operation. Ann Surg 1990;211:521-537.[Medline]
4. Coselli J.S., LeMaire S.A., Miller C.C., 3rd, Schmittling Z.C., Koksoy C., Pagan J., Curling P.E. Mortality and paraplegia after thoracoabdominal aortic aneurysm repair: a risk factor analysis. Ann Thorac Surg 2000;69:409-414.[Abstract/Free Full Text]
5. Svensson L.G., Crawford E.S., Hess K.R., Coselli J.S., Safi H.J. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993;17:357-368 discussion 368–370.[Medline]
6. Fann J.I., Dake M.D., Semba C.P., Liddell R.P., Pfeffer T.A., Miller D.C. Endovascular stent-grafting after arch aneurysm repair using the ‘elephant trunk’. Ann Thorac Surg. 1995;60:1102-1105.[Abstract/Free Full Text]
7. Zarins C.K., White R.A., Hodgson K.J., Schwarten D., Fogarty T.J. Endoleak as a predictor of outcome after endovascular aneurysm repair: AneuRx multicenter clinical trial. J Vasc Surg 2000;32:90-107.[Medline]
8. Wolf Y.G., Hill B.B., Rubin G.D., Fogarty T.J., Zarins C.K. Rate of change in abdominal aortic aneurysm diameter after endovascular repair. J Vasc Surg 2000;32:108-115.[Medline]
9. Wever J.J., de Nie A.J., Blankensteijn J.D., Broeders I.A., Mali W.P., Eikelboom B.C. Dilatation of the proximal neck of infrarenal aortic aneurysms after endovascular AAA repair. Eur J Vasc Endovasc Surg 2000;19:197-201.[Medline]
10. Resch T., lvancev K., Brunkwall J., Nyman U., Malina M., Lindblad B. Distal migration of stent-grafts after endovascular repair of abdominal aortic aneurysms. J Vasc Interv Radiol 1999;10:257-264.[Medline]

This article has been cited by other articles:

				R. K. Greenberg, F. Haddad, L. Svensson, S. O'Neill, E. Walker, S. P. Lyden, D. Clair, and B. Lytle Hybrid Approaches to Thoracic Aortic Aneurysms: The Role of Endovascular Elephant Trunk Completion Circulation, October 25, 2005; 112(17): 2619 - 2626. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wong, C.H. Articles by Hasan, A. Search for Related Content PubMed PubMed Citation Articles by Wong, C.H. Articles by Hasan, A. Related Collections Great vessels