| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Eur J Cardiothorac Surg 2005;28:478-482
© 2005 Elsevier Science NL
Original articles |
a Postgraduate School in Vascular Surgery—Department of Surgery, University of Insubria, Ospedale di Circolo, 21100 viale Borri 57, Varese, Italy
b Department of Radiology, University of Insubria, Varese, Italy
c Anesthesia and Palliative Care, University of Insubria, Varese, Italy
Received 12 April 2005; received in revised form 23 May 2005; accepted 25 May 2005.
* Corresponding author. Tel.: +39 3322 78226; fax: +39 3322 60260. (Email: lelepiffa74{at}libero.it).
Abstract
OBJECTIVE: Patients with multilevel aortic disease represent a small subgroup with the need for extensive surgical treatment at considerable risk. We present our experience of endovascular exclusion for simultaneous thoracic and abdominal aortic disease in four patients. Methods: Between January 2002 and January 2005, four patients underwent endovascular repair for simultaneous thoracic and abdominal aortic disease. Mean age was 69±10 years (range, 60–81). Thoracic lesions included penetrating aortic ulcer (n=2, ruptured=1), atherosclerotic aneurysm (n=1), and chronic type B dissection (n=1). Abdominal aortic disease included atherosclerotic infrarenal (n=3) and juxtarenal (n=1) aortic aneurysms. Thoracic aortic stent-grafts had been the following: Excluder/TAG (n=3) or Talent (n=1) straight tube devices. Abdominal aortic stent-grafts used were as following: Excluder (n=3) or Zenith (n=1). All patients were followed-up with CT-angiography and chest X-rays 1, 4, 12 months after the procedure, and once per year thereafter. Results: Stent-graft deployment was technically successful in all cases. Intraoperative mortality was not observed. Mean procedure time was 94±34min (range, 70–145). Early postoperative complications occurred in one patient that developed acute renal failure but dialysis was not required. Mean hospitalisation was 8±5 days (range, 4–15). Late death occurred in one patient for an undetected ruptured thoracic type 1 endoleak. All three survivors are currently well 16.5 months (range, 3–36) after surgery. No neurological complications developed. Conclusion: Simultaneous abdominal and thoracic endovascular repair for multilevel aortic disease is feasible and could be a viable alternative in high-risk patients, who otherwise may not be suitable candidates for conventional repair.
Key Words: Multilevel aortic disease • Endovascular repair • Stent-graft • Penetrating aortic ulcer
1. Introduction
Multilevel aortic disease present a formidable challenge for cardiovascular surgeons in the terms of choice of an adequate surgical method of treatment. Historically, multilevel aortic surgery was performed simultaneously or subsequently: single-stage intervention has been reported to be associated with high complications, whereas sequential repair requires two major surgical interventions, and rupture of the residual lesion can occur while waiting the second operation [1–3]. Endovascular treatment has been suggested as a viable alternative to treat both the diseased aortic areas; it could allow for a lower complication risk than for a procedure associated with open thoracotomy and aortic cross-clamping. However, few brief published data reported separate stent-grafts (SG) were used to repair isolated thoracic and abdominal aortic aneurysms during a single procedure [4–6]. Combined endovascular SG placement could effectively exclude both areas of aortic disease without the added morbidity of a thoracic incision or second operation. We report our single centre experience of simultaneous endovascular repair of known thoracic and abdominal aortic disease in four patients.
2. Materials and methods
Between January 2002 and January 2005, four male patients with coexisting thoracic and abdominal aortic disease underwent simultaneous SG treatment of the lesions. Mean age was 69±10 years (range, 60–81). All patients from this group suffered significant co-morbidities including hypertension (n=4), chronic obstructive pulmonary disease (n=4), hypercholesterolemia (n=3), history of myocardial infarction (n=2), chronic renal failure (1) and diabetes (n=1); demographic data and procedures details are summarized in Table 1 . Before surgery, CT-A (Fig. 1 ) was obtained of the thoraco-abdominal aorta to measure thoracic and abdominal aortic diameter, evaluate the branch vessels and iliac arteries, to identify the origin of the renal arteries, to determine the relationship with the origin of the left subclavian artery (LSA), with evaluation for SG implantation. Digital subtraction angiography (DSA) was never performed preoperatively. All thoracic lesions originated below the LSA and included penetrating aortic ulcer (PAU) (n=2, ruptured=1), atherosclerotic aneurysm (n=1), and chronic type B dissection (n=1). Abdominal aortic disease included atherosclerotic infrarenal (n=3) and juxtarenal (n=1) aortic aneurysms. Mean abdominal aortic aneurysm (AAA) diameter was 67±13mm (range, 5–8). Mean thoracic aortic lumen measured 33.5mm (range 30–38mm).
|
|
/kg/min) plus N-acetylcysteine (600mg i.v.)] against the ischemic-related delivery of free-radicals and the renal damage due to the contrast medium. No cerebrospinal fluid drain was placed. Trans-esophageal ecochardiography (TEE) was used to control ‘real-time’ the SG deployment and lesion exclusion. The fluoroscopic machine (Isocentric mobile C-arm-Siemens®; Munich, Germany) was opposite to the first operator. Through a left percutaneous brachial access, a 5-F pigtail catheter was advanced over a 0.035-inch guidewire (Boston Scientific/Medi-tech®-Natick, MA, USA) to the thoracic aorta for preliminary angiography and intraprocedural control. Femoral artery was surgically exposed, and an Amplatz guidewire was advanced through the sheath and secured in the root of the ascending aorta. The device was then advanced under fluoroscopic guidance through the femoral artery into the aorta and deployed under TEE control. With satisfactory deployment of the thoracic SG, the diagnostic catheter was repositioned with its tip just above the origin of the renal arteries, and the bifurcated graft was deployed and molded with a balloon catheter. Final DSA was performed in order to detect endoleak or any potential SG complication (Fig. 2
). Thoracic aortic SGs included Excluder/TAG [W.L.Gore & ass.®-Flagstaff, AZ, USA (n=3)] or Talent [Medtronic inc®-Minneapolis, MN, USA (n=1)] straight tube devices. Abdominal aortic SGs used were as following: Excluder [W.L. Gore & ass.®-Flagstaff, AZ, USA (n=3)] or Zenith [Cook Inc®-Bloomington, IN, USA (n=1)]. Postoperatively, pre-discharge CT-A was carried out to confirm lesions exclusion and device-related complications. Follow-up program included simultaneous CT-A and chest X-rays 1, 4, 12 months after the intervention, and every year thereafter (Fig. 3
).
|
|
SG deployment was technically successful in all cases. Intraoperative mortality was not observed. Three patients were adequately treated with one SG, whereas one patient required two SGs to exclude the area of the thoracic disease. Mean procedure time was 94±34min (range, 70–145); median volume of non-ionic contrast used was 120mL (range, 100–150). Mean blood loss was 105mL (range, 50–210). Median thoracic SG length was 10.75cm (mean 14±7, range 10–25). All patients were extubated at the end of the operation and admitted directly to ward, where they were noted to be neurologically intact. No patient was transferred to intensive care unit (ICU). Early postoperative complications occurred in one patient that developed acute renal failure (creatinine level: 6.51mg/L) but dialysis was not required; he was known to have chronic renal failure and presented with hemorrhagic shock following the rupture of a thoracic penetrating ulcer. He was discharged uneventful. Mean hospitalisation was 8±5 days (range, 4–15); overall, in-hospital mortality was not observed. In all patients pre-discharge CT-A confirmed the complete exclusion of both the thoracic and abdominal lesions, and no endoleak. Late death occurred in one patient for an undetected ruptured thoracic type 1 endoleak, despite the last follow-up CT-A performed 8 months before the fatal event, did not reveal any device complication. All three survivors are currently well 16.5 months (range, 3–36) after surgery; further device complications (such as endoleak, breakage, migration, kinking and twisting) were not observed. We did not detect endoleak or SG complications (such as migration, aneurysm expansion, and any other complications associated with thoracic SG placement); no neurological complications developed during this follow-up time.
4. Discussion
The estimated incidence of simultaneous thoracic and abdominal aortic disease is approximately 10–20% of the patients [1–5]. There is a very little data available for combined thoracic and abdominal aneurysm repair; historically simultaneous thoracic and abdominal aortic disease repair showed to be a challenging surgical procedure. Crawford advocated an initial repair of the thoracic lesion in asymptomatic patients [1,3]. While waiting for the second operation, the AAA is easier to observe, and if symptoms or rupture occur patients could potentially survive to attempt repair, whereas TAA are more likely to rupture without warning and are rapidly fatal within minutes. However, on the other hand 30% of the reported deaths after descending thoracic aneurysm repair has been associated with co-existing untreated infrarenal aneurysm rupture [3,7]. With the development of endovascular SG technology, staged and simultaneous repairs of concomitant thoracic and abdominal aneurysms have been yet published, but these have mainly employed combined open and endovascular techniques [8–10], as opposed to our use of simultaneous endovascular repair of both diseased aortic areas, particularly for high risk patients. Although guidelines have never been produced, and some authors suggested no reason for endovascular AAA repair in patients without significant risk factors, we believe both aneurysms could be excluded simultaneously, since this seems a much simpler and less invasive approach. If anatomic criteria confirm the feasibility of the endovascular approach and operative risks are not prohibitive, synchronous repair might be always considered the alternative therapy for multilevel aortic disease.
It has been reported that following planned resection of only one aortic lesion, the 3-year and 7-year survival rates were 48 and 12% respectively, compared with 32 and 2% for patients who received no treatment but 64 and 34% in patients who underwent resection of both diseased areas [1,2,4–7]. Thus complete repair of multilevel disease could provide the best early and long-term prognosis and could be advocated as the treatment of choice. In the current series, our mortality rate compares favourably with other series, though it reports only few cases; moreover, SG treatment has been associated with fewer early complications and deaths than simultaneous or sequential conventional repair in high-risk patients, despite long-term efficacy and clinical outcome remains uncertain [3,8–10]; therefore, elderly patients with co-existing cardiopulmonary diseases would most benefit from a less invasive, but nonetheless complete, repair of this challenging procedure.
PAU has been first described in 1986 and reported to affect elderly patients with advanced atherosclerosis and risk factors [11]; hence, PAU is potentially associated with a high incidence of morbidity (such as hypertension, coronary artery disease, and carotid artery occlusive disease). All four patients in this series have received anti-hypertensive drugs, and two patients had history of ischemic heart disease; also, our experience is consistent with other published series reporting typical involvement of the descending thoracic aorta [12–15]. Some authors believe immediate surgical treatment is not always required, because most PAU have a benign clinical course [12]. However, early intervention is recommended when PAU is complicated with aneurysm expansion, rupture, embolic symptoms, or uncontrolled pain [12–15]. Moreover, few published reports speculated that some spontaneous aortic ruptures in elderly patients may be due to perforation of PAU; of the two patients presented in our series, one was admitted with mediastinal hematoma following rupture of a descending thoraco-abdominal PAU. Open surgical repair with graft interposition has been used for such symptomatic PAU, but as we overmentioned, patients with PAU are generally not ideal candidates for open repair because, of advanced age and poor general status. Both patients of our series presented poor cardio-respiratory function that make them unsuitable for conventional repair; hence, endovascular SG was suggested. Moreover, review of the cases reported to date, revealed that SG treatment was successful in all cases [12–15]. The lower morbidity and mortality after SG repair for PAU should supports a more aggressive approach to this lesion, even in patients with acute syndromes or symptoms.
An important consideration in the patient's preoperative profile requiring careful attention relates to renal dysfunction, because postoperative renal failure after thoraco-abdominal aortic surgery continues to be a significant and potential lethal complication; moreover, the incidence of worsening renal function increases two-to threefold in those patients with pre-existing renal insufficiency [16,17]. Nevertheless, the association between contrast volume and nephrotoxicity remains controversial using endovascular technique, also because remains poorly documented [16,17]; in addition, the risk for worsening renal failure has been reported significantly increased in patients with pre-existing chronic renal failure and associated diabetic nephropathy or renovascular occlusive disease [16]. Three mechanism could be probably related to the case of renal failure we experienced in one patient only: a much larger volumes of contast agent used, the preoperative known chronic renal failure and the organ hypoperfusion due to the severe hemorrhagic shock presented at the admission.
Even with the availability of SGs, the increased risk of spinal cord ischemia and paraplegia when treating thoraco-abdominal aortic diseases should be considered when deciding upon the best course of patient management [18,19]. When the interruption of the blood supply from the intercostal arteries is done, the most critical factor of this intervention has been reported to be the aortic cross-clamp time [19]. Although also endovascular SG is not immune to paraplegia, the sudden deployment of the SG involved a shorter aortic cross-occlusion time and not produces a steal phenomenon in the perfusion of the spinal cord that could probably explain the lower than reported paraplegia rate. This should not, of course, be extrapolated to mean a zero risk of paraplegia with this procedure, as SG repair of aortic pathology does not allow for re-implantation of intercostal arteries; however, we did not observed transient or definitive neurological defects neither in the postoperative course nor at 16 months follow-up period.
Apart from surgical mortality, isolated cases of secondary rupture after SG have been described in many reports: in all of these cases, technical errors of untreated primary or secondary endoleaks could be incriminated [20,21]. Despite every patient underwent a tight follow-up program with periodical chest X-rays and CT-A examinations, in the present series, we experienced fatal outcome following the rupture of an undetected endoleak; in fact, successful and complete sealing of the aneurysm was confirmed for the first 24 months after the SG procedure, as the last CT-A 8-months before the fatal event documented.
5. Conclusions
Simultaneous abdominal and thoracic endovascular repair for multilevel aortic disease is feasible and can safely be performed and offered in high-risk patients, who otherwise may not be suitable candidates for conventional repair. Our preliminary results seem to be encouraging; however long-terms studies should be warranted.
One major tool is that endovascular repair requires a great deal of organization and is likely to be possible at major vascular centres only, with an emergency endovascular team with personnel competent in both open and endovascular techniques, and involved the availability of a wide SG inventory to treat the wide spectrum of aortic diseases and diameters.
Footnotes
To be presented at the 15th World Congress of the World Society of Cardiothoracic Surgeons, Vilnius, Lithuania, June 19–23, 2005. 
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
