Eur J Cardiothorac Surg 2003;24:379-387
© 2003 Elsevier Science NL
Acceptable short-term results after endovascular repair of diseases of the thoracic aorta in high risk patients
Kirsten Krohg-Sørensena*,
Geir Hafsahlb,
Erik Fosseb,
Odd R. Geirana
a Department of Thoracic and Cardiovascular Surgery, Rikshositalet University Hospital, N-0027 Oslo, Norway
b The Interventional Centre, Rikshositalet University Hospital, N-0027 Oslo, Norway
Received 20 January 2003;
received in revised form 30 April 2003;
accepted 12 May 2003.
* Corresponding author. Tel.: +47-230-70879; fax: +47-230-73741
e-mail: kirsten.krohg-sorensen{at}rikshospitalet.no
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Abstract
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Objective: To report our experience with endovascular stentgraft repair of diseases of the descending thoracic aorta in high risk patients. Methods: Twenty-one procedures were performed in 20 patients (10 women), aged 22–81 years, for disease of the descending thoracic aorta with the Gore Excluder thoracic endoprosthesisTM (WL Gore) (n=11) and the Talent LPS Stent Graft System (Medtronic AVE) (n=10). All patients were considered high operative risk. Diagnoses included saccular aneurysm, aneurysm rupture, mycotic aneurysm, penetrating atherosclerotic ulcer, aortic dissection and aortitis. The access vessels were a tube graft of the (thoraco-) abdominal aorta (n=4), the common iliac (n=6) and the common femoral artery (n=11). Several patients needed major cardiovascular surgery for concomitant disease during the same stay. Computed tomography scan and chest X-ray was performed at 3 and 6 months and thereafter every sixth month postoperatively. Results: Two patients died. One had a colon perforation 8 days postoperatively and died after 3.5 months, and the other with preoperative sepsis and a mycotic aneurysm died on day 11 from cardiac and renal failure. In one patient the stentgraft dislocated during release, and an additional stentgraft had to be implanted 1 week later to treat the proximal leak. In another patient the stentgraft could not be released from the introducer, and was pulled back to the aortic bifurcation and retrieved through laparotomy. Eighteen patients have been followed for 1–24 months, and no migration, wire fractures or endoleak have been seen. There were no neurologic complications. One patient treated for infected pseudoaneurysm had a chronic graft infection. Conclusion: In this small number of patients with high operative risk, short-term results of endovascular stentgraft repair of variable diseases of the descending aorta have been satisfactory. Stentgraft repair could be a valuable supplement to surgery for patients with complex multilevel or multiorgan disease.
Key Words: Endovascular treatment • Aortic disease
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1. Introduction
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Open surgical repair of the descending thoracic aorta is associated with a considerable peri- and postoperative morbidity and mortality [1,2]. Endovascular repair with stentgraft has been introduced as an alternative treatment, with the anticipation that a lesser surgical trauma will reduce the risk of cardiac, neurologic and renal complications [1–4]. However, the durability of stentgraft repair has been questioned, and from experience with infrarenal aneurysms a large number of reinterventions are necessary and aneurysm rupture after stentgraft repair has also been described [5–7]. A randomised trial has been started to determine the role of endovascular repair of infrarenal aneurysms [8]. In thoracic aortic disease, the situation is even more complex with regard to randomised trials, since stentgraft treatment has been offered to patients with a variety of diagnoses like dissections, penetrating atherosclerotic ulcers and trauma as well as aneurysms of different aetiology. Also in thoracic aortic stentgrafts, metal wire fractures and device-related complications have been reported [2], and the indications for endovascular repair of thoracic aortic diseases are so far not defined.
We have offered this treatment to patients with high surgical risk, who were anatomically well suited for stentgraft repair. We wish to report the short-term results in these patients with different aetiology of disease of the descending thoracic aorta.
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2. Patients and methods
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Our hospital is a referral centre for thoracic and cardiovascular disease. Between July 2000 and December 2002, 24 patients with thoracic and 81 patients with thoracoabdominal aortic disease were treated with open repair. During the same period 21 stentgraft implantations for thoracic aortic disease were performed in 20 patients (10 women). Nine patients had degenerative aneurysms (four elective, three symptomatic and two ruptured), three had mycotic aneurysms and two had false aneurysms after previous surgery (one with aortobronchial fistula and one with infected prosthesis). Three patients had aortic dissection (one chronic and one acute type B dissection and one type A dissection with cardiac tamponade and rupture). Two patients had penetrating atherosclerotic ulcers with rupture and one patient had Takayasu's aortitis with rupture (Table 1). Median age was 73 years (range 22–81). The Gore Excluder thoracic endoprosthesisTM (Gore AB) was used in 11 patients and the Talent LPS Stent Graft System (Medtronic AVE) in nine patients (10 procedures). All patients were considered high risk for open surgery (Table 1). Informed consent was obtained from all patients or a family member. Nineteen procedures were performed under general anaesthesia, one with spinal and one with epidural anaesthesia. When using the Gore Excluder, the systolic blood pressure was lowered to around 80 mmHg with beta-blocker and nitroprusside before release of the stentgraft. With the Talent stentgraft, despite lowering the pressure, we experienced distal dislocation of the stentgraft during release due to ‘wind-sock’ effect (patient 3), and now use adenosine to induce ventricular asystole during release.
Most procedures were performed in an operation theater equipped with angiography in the Interventional centre. When this was not available the procedures were done in an angiography suite at the Department of Radiology. Patients 4 and 15 who had concomitant thoracolaparotomy, were treated in the operation theatre of the Department of Thoracic and Cardiovascular surgery, using a mobile C-arm for angiography. The preoperative diagnostic procedures were computed tomography (CT) scan and magnetic resonance angiography (MRA)—in some patients combined with a graded catheter angiography. Length and diameter of the proximal and distal aneurysm necks, and length of the aneurysm was measured, as well as diameter and angulation of the femoral and iliac vessels. Table 1 shows the type, number and length of stentgrafts that were implanted. One to four overlapping stentgrafts of 10–18 cm length were placed, covering 10–27 cm of the descending aorta. Patients were excluded if the proximal or distal neck was shorter than 20 mm, and if there was severe tortuosity of the distal descending aorta. The stents were oversized 15–20% compared to the aortic diameter. From the beginning only patients where the stentgrafts could be placed distal to the left subclavian artery were included, but lately the left subclavian artery has been intentionally covered on two occasions (patient 3 (Fig. 1
) who had a chronically occluded subclavian artery and patient 13 (Fig. 2
)). Follow-up with CT or MRI, and chest X-ray has been done before discharge, after 3 and 6 months, and thereafter every sixth month.
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Fig. 1. Patient 3. A: Preoperative MRA showing large saccular aneurysm distal to a chronically occluded left subclavian artery. B: CT-scan 3 months postoperatively showing excluded aneurysm.
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Fig. 2. Patient 13. A: Preoperative angiography showing pseudoaneurysm in the patch after surgery for coarctation and aneurysm of the ascending aorta. B: CT-scan 3 months postoperatively.
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2.1. Other necessary procedures
Sixteen of the 20 patients needed additional procedures, either for access problems, to treat complications or to treat multilevel aortic disease or other comorbidities. Table 2 lists all the performed procedures.
2.1.1. Access
Access from the femoral artery was possible in 11 procedures, in two after PTA of iliac artery stenosis. One patient had a PTFE graft for femoral artery aneurysm during the procedure. On six occasions, the common iliac artery or a limb of bifurcation prosthesis (second procedure in patient 3) was used as access vessel. In one patient a previously implanted aortic tube prosthesis was dissected through a retroperitoneal incision, and a side branch (10 mm PTFE) sutured to it for access. Concomitant open surgery of the abdominal aorta and endovascular repair of thoracic aortic disease was done on three occasions. Patient 3 with abdominal aortic aneurysm (AAA), as well as a large saccular aneurysm of the descending aorta (Fig. 1) was operated with laparotomy and an infrarenal bifurcation prosthesis. Patient 4 had a large thoracoabdominal aneurysm, with occlusion and stenosis of the iliac vessels, and also a large aneurysm of the descending aorta. A bifurcation prosthesis to both femoral arteries was inserted, and the intestinal and renal arteries were reimplanted. Patient 15 with acute type B dissection localised in a short segment of the descending aorta, also had a Crawford type IV aneurysm. In all three patients the stentgraft to the descending aorta was introduced through a side branch sutured to the aortic prosthesis.
2.1.2. Other additional surgical procedures during the same stay
Patient 17 was admitted to the emergency room with aortic dissection type A and tamponade, and taken to surgery. The ascending aorta was dissected, but no entry tear could be localised. A supracoronary prosthesis was implanted. The postoperative CT-scan showed the entry site and a saccular aneurysm distal to the left subclavian artery, mediastinal hematoma and hemothorax. A stentgraft was implanted to cover the aneurysm at the entry site. Follow-up is incomplete as he was a foreign tourist, but he was clinically well 4 months postoperatively.
Patient 13 (Fig. 2) was previously operated 22 and 15 years ago for coarctation, the last time with rupture. He was admitted to the emergency room with hemoptysis and CT showed a large pseudoaneurysm in the patch in the proximal descending aorta. The patient also had a fusiform aneurysm of the ascending aorta with severe aortic valve regurgitation. Stentgraft repair of the pseudoaneurysm was done as an emergency procedure, covering the left subclavian artery. A small proximal endoleak was suspected at the completion angiogram. One week later resection of the ascending aorta and arch with a valved aortic conduit was performed, with reimplantation of the coronary and arch vessels. Under circulatory arrest, the stentgraft was then sutured to the inside of the aortic arch between the left carotid and left subclavian artery. The subclavian artery was not revascularized, and this caused no symptoms. At 3 months follow-up, the patient was well and CT showed no endoleak.
Patient 18 was admitted with chest pain. He had critical coronary artery disease with left main stem stenosis as well as a penetrating ulcer of the thoracic aorta with intramural hematoma and blood in the left pleural cavity. He was treated with a Gore Excluder stentgraft of the descending aorta, and 10 days later with coronary artery bypass graft (CABG). He has been followed for 1 year postoperatively without complications.
2.2. Infection
Patient 10 with mycotic aneurysm (Fig. 3
) had Staphylococcus aureus in blood cultures. A Gore Excluder stentgraft was implanted, and at 15 months she was well, without any sign of infection, and total disappearance of the aneurysm on the CT-scan.
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Fig. 3. Patient 10. A and B: CT-scan preoperatively showing large mycotic aneurysm. C: CT-scan immediate postoperatively. Excluded aneurysm. D: CT-scan 15 months postoperatively. Aneurysm has disappeared.
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Patient 11 had Streptococcus in blood cultures and arthritis with pus in the ankle and one finger joint. She had been treated for some weeks with drainage and antibiotics at the local hospital for left-sided empyema and sepsis, when a CT control showed a saccular aneurysm of the descending aorta (Fig. 4
). A stentgraft was implanted and at 18 months she is without sign of infection, and with shrinkage of the aneurysm on CT.
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Fig. 4. Patient 11. A: CT-scan preoperatively showing mycotic aneurysm and pleural empyema. B: CT-scan 18 months postoperatively. Excluded shrinking aneurysm.
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Patient 12 had been treated for a streptococcal sepsis. She had splenic infarcts and arthritis of an ankle joint, and was operated for an abscess of the cervical epidural space 1 month before endovascular treatment of her mycotic thoracic aneurysm. Patient 14 was operated 2 months previously for ruptured aneurysm of the descending aorta, and was readmitted with a large pseudoaneurysm of the distal anastomosis, pleural effusion with growth of Staphylococcus epidermidis, and elevated C-reactive protein. The aneurysm was excluded with a stentgraft, and after 3 months there was no endoleak, but a chronic graft infection was suspected. Antibiotic treatment is continued, and if his general condition improves, radical surgery might be possible later.
2.3. Aortitis
Patient 20 with aortitis was an African woman, operated 13 months previously with a prosthesis of the proximal descending aorta for aortitis with ulcers and periaortal hematoma. Two months later she was operated with a valved aortic conduit for ascending aortic aneurysm and severe aortic regurgitation. The descending aorta distal to the prosthesis developed aortitis with several deep ulcer of the thickened aortic wall and periaortal hematoma. Also severe stenoses due to thickening of the arterial wall were found in all supraortic branches. A stentgraft was placed from the prosthesis in the descending aorta to the coeliac trunc. After this treatment for Takayasu’s disease with steroids and cyclophosphamide has been started. MRI at 3 months showed no endoleak and no progression of arteritis.
2.4. Rupture
Seven patients had aortic rupture (pats. 8, 9, 13, 17, 18, 19 and 20), with either intramural hematoma, mediastinal hematoma, hemothorax or aortobronchial fistula (Table 1). They have all been stabilized to wait 4–24 h for diagnostic evaluation and delivery of stentgraft. Patient 8 was an 80-year-old woman with a saccular aneurysm of the descending aorta, hemothorax and hemoglobin concentration of 7 g/100 ml on arrival. Patient 9, a 66-year-old man, was in dialysis, and had a ruptured saccular aneurysm of the descending aorta with hemothorax. Patient 19 had several deep atherosclerotic ulcers of the descending aorta and hemothorax with 1.6 l of blood. He also had triple vessel coronary artery disease. After implantation of four overlapping stentgrafts through the whole length of the descending aorta, CABG is planned after 4 weeks. Patients 13, 17, 18 and 20 have already been described.
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3. Results
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Two patients have died. Patient 7 suffered a perforation of the coecum on the eighth postoperative day after transfer to her local hospital. This was complicated with sepsis. She was operated with ileocecal resection and primary anastomosis of the bowel, but developed respiratory failure and had a long ICU stay. She died in a nursing home 3.5 months postoperatively. No autopsy was done. Embolisation from the descending aorta to branches of the superior mesenteric artery during the implantation could be the cause, though this was not registered. Another possibility in this 78-year-old woman is ischemic colitis due to relative hypotension. Patient 12 with mycotic aneurysm died 11 days postoperatively at a local hospital, according to the report from heart and renal failure, but autopsy was not performed. The other 18 patients are all alive and the last follow-up details are shown in Table 1. There has been no neurological complications. At follow-up after 1–24 (median 8) months, we have not seen any endoleak, migration or metal wire fractures.
3.1. Complications
(Table 2) In patient 13 a laparotomy was necessary to retrieve a Talent stentgraft that could not be released from the introducer sheath and was pulled back to the aortic bifurcation. Patient 3 needed a secondary procedure 1 week later to obtain proximal seal, as the proximal stent dislocated distally during the primary procedure. In patient 7, PTA/stent at the arteriotomy in the common iliac artery was necessary to achieve sufficient flow after closure. Patient 5 had a postoperative retroperitoneal hematoma and needed transfusions.
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4. Discussion
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The literature on stentgraft repair of the thoracic aorta include different indications like aneurysms, dissections, trauma and penetrating atherosclerotic ulcers [1–4,9–14], and stentgrafts have been used both in the acute and chronic presentation. With small and heterogeneous patient materials, lack of randomised studies, and short follow-up, the true value of stentgraft repair of diseases of the thoracic aorta cannot be evaluated and is so far unknown.
The results of stentgraft repair of AAAs have caused concern as devices have been withdrawn due to material breakdown and device-related complications [15]. Also distribution of the Gore Excluder thoracic endoprosthesis was suspended in November 2001 due to reports of metal wire fractures, which has been reported to cause rupture [2]. Placement of the device in a tortuous aorta is believed to increases the risk of fatigue-related wire fractures. The durability of these devices is thus questioned.
We have adopted a careful strategy for stentgraft repair of the thoracic aorta. The patients have been considered very high risk for open repair. Open surgery for aortic disease of the descending thoracic aorta is our routine treatment for surgically fit patients. Hemodynamically unstable patients with rupture have been treated with open surgery if considered operable, and the seven patients with rupture treated with stentgraft have been stabilized to wait for diagnostic examination, stentgraft delivery and implantation.
We have also been critical to the anatomical criteria, including only patients where the stentgraft could be placed in a fairly straight portion of the descending aorta with at least 20 mm proximal and distal neck. Still we have included two patients where the left subclavian artery was covered by the stentgraft. One had a chronically occluded subclavian artery. In the other patient ischemia of the arm was not seen, and no endoleak due to retrograde perfusion from the subclavian artery was registered at the 3 months follow-up.
Access from other sites than the femoral artery was necessary in almost half of the procedures. This has also been noted by others [2]. There are probably several reasons for this, including larger bore introducers and a higher proportion of women than in AAA materials. Also patients with atherosclerotic ulcers and saccular and mycotic aneurysms might be more prone to iliac vessel atherosclerosis than patients with degenerative fusiform aneurysms. The access site should be planned preoperatively to avoid iatrogenic injuries, and in our experience preoperative MRA of the iliac vessels has been useful.
The three patients with mycotic aneurysms, and the one with an infected pseudoaneurysm represent a special challenge. There are a few reports in the literature on stentgraft treatment of mycotic aneurysms [11]. If the patients had been fit for open surgery, the alternative would be debridement, in situ repair with a prosthesis or homograft, and transposition of viable tissue. In situ repair is associated with a risk of graft infection, and certainly this risk is also present with endovascular repair. Possibly the stentgraft repair can ‘buy time’ to improve the patients general condition, so that a more radical open repair can be tolerated at a later stage if necessary.
There are several reports in the literature on endovascular repair of penetrating atherosclerotic ulcers with rupture [9,10]. We have treated two such patients. In patient 18 there was one obvious lesion that was covered with one stentgraft. In patient 19 several deep ulcers were found on CT-angiography, located from the arch to the diaphragm, and the intramural hematoma also spread through the whole length of the descending aorta. As it was impossible to locate the exact rupture site, the whole descending aorta was covered with four stentgrafts.
Combined open and endovascular treatment of abdominal and thoracic aortic disease has been described by others [14]. Multilevel aortic disease is common, and in our own experience 30% of patients with thoracoabdominal aneurysms have previously been operated for infrarenal aneurysms. Combined or sequential open repair is associated with high mortality and morbidity, and the lesser trauma of a combination of open and endovascular repair might be of benefit to some patients, although this remains to be proven.
We did not see complications related to spinal cord ischemia. From this small and heterogeneous material, obviously no conclusion can be drawn as to whether the risk of neurological complications is reduced with endovascular treatment compared to open surgery. This problem probably needs to be addressed in randomised trials or register data.
It is our belief that stentgraft repair of descending thoracic aortic disease currently is developing as a supplement for treatment of patients with complex multilevel or multiorgan, disease, who often need several surgical procedures. A multidisciplinary approach, involving thoracic and vascular surgeons as well as interventional radiologists is necessary. The experience so far is very limited and the follow-up is short. Results of randomised studies for some of these heterogeneous clinical problems might never be available, and it is therefore important that all centres report their experience. Endovascular repair is still experimental treatment, and in our view should not be recommended to patients with an acceptable surgical alternative, unless a part of a clinical study. With the current technology saccular aneurysms and penetrating ulcers might be the better indications than aneurysms in dissections and fusiform aneurysms.
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Top
Abstract
1. Introduction
