Eur J Cardiothorac Surg 2008;33:1148-1149. doi:10.1016/j.ejcts.2008.03.041
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Emergent antegrade endovascular stent placement in a patient with perforated Stanford B dissection via right axillary artery
Chris Probsta,*,
Bahman Esmailzadeha,
Wolfgang Schillera,
Kai Wilhelmb
a Department of Cardiac Surgery, Heart Center Bonn, University of Bonn, Germany
b Department of Radiology, University of Bonn, Germany
Received 17 January 2008;
received in revised form 13 March 2008;
accepted 14 March 2008.
* Corresponding author. Address: Department of Cardiac Surgery, University of Bonn, Sigmund Freud Str. 25, 53127 Bonn, Germany. Tel.: +49 228 287 4190; fax: +49 228 287 5591. (Email: chris.probst{at}ukb.uni-bonn.de).
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Abstract
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We present a case of a ruptured chronic Stanford B dissection of the aorta which was successfully treated with a tapered endoprosthesis using the right axillary artery for access. Challenges to endovascular strategies for thoracic aortic pathology include relatively restricted endoprosthesis configurations and problems associated with endovascular access. Especially in younger patients the right axillary artery should be considered as a possible and safe access for antegrade stent placement.
Key Words: Endovascular stent placement • Aortic dissection • Cardiac surgery
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1. Introduction
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Open surgical treatment of acute pathologies of the descending thoracic aorta is associated with significant mortality and morbidity. Whereas in elective treatment the mortality rate for surgical repair of descending aortic pathologies varies between 6% and 10%, this percentage increases as much as six fold in patients requiring emergent surgical treatment [1]. Endovascular approaches are being increasingly utilized to treat a variety of thoracic aortic pathologies, including aneurysms, dissections, and perforations [2,3]. Ongoing challenges to endovascular strategies for thoracic aortic pathology include relatively restricted endoprosthesis configurations and problems associated with the retropath endovascular access. Here we present a case of a ruptured chronic Stanford B dissection treated with a tapered endoprosthesis using the right axillary artery for access.
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2. Case report
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A 48-year-old obese female patient with a history of a chronic conservatively treated Stanford type-B dissection of the aorta diagnosed in 2002 was admitted to the hospital complaining of dyspnea and severe thoracic pain. A 64-detector MDCT was obtained and showed a large aneurysm distal to the left subclavian artery with signs of perforation and a consecutive left sided hematothorax. Because of the patient's chronic obstructive pulmonary disease, the obesity, and the chronic dissection of the abdominal aorta including both iliac and femoral arteries, conventional open-chest surgery was judged to be prohibitive. The patient was scheduled for emergent stent implantation into the descending aorta. The right axillary artery was chosen for access for antegrade stent delivery (Figs. 1B and 2A
). The axillary artery was exposed through an incision that was made inferior and parallel to the lateral two thirds of the clavicle. The pectoralis major muscle was divided in the direction of its fibers. The clavipectoral fascia was incised and the pectoralis minor muscle was exposed. The axillary artery was seen superior to the axillary vein. The proximal and distal parts of the axillary artery were controlled with Silastic tape and a 4-0 prolene circled suture was placed. Then we introduced a guidewire and placed it into the descending aorta (Fig. 1B). Additionally, a 6 Fr pigtail catheter was advanced from the left radial artery to allow intra-procedural angiography. We used a GoreTag© Stent of 40 mm diameter and 150 mm length to cover the aneurysm and the perforation with a 20 Fr introducer sheath. Intraoperative angiogram showed a good result after stent placement (Fig. 2B), which was confirmed by CT-scan at time of discharge. The postoperative course was uneventful and the patient was discharged after 10 days for rehabilitation.
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Fig. 1. (A) Volume rendered reconstruction of a 64-slice MDCT of the ruptured Stanford B aortic dissection. (B) Intraoperative angiography of the ruptured dissection of the descending aorta (arrow*) with the leading wire coming from the right axillary artery (arrows).
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Fig. 2. (A) Stent introducer system in position (arrows). (B) Angiographic control after stent release showing the total exclusion of the perforated aneurysm (arrows).
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3. Discussion
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In the past decade, we have witnessed rapid growth in the use of an endovascular aortic stent graft to treat thoracic and abdominal aortic aneurysms. Endovascular repair has been widely accepted by patients and surgeons, due to the procedure's low morbidity and mortality [2–4]. Endovascular stent grafting is a less invasive treatment for descending thoracic aorta pathology and may be considered as an alternative treatment option for open surgical repair in emergent patients with suitable aortic anatomy. In the thoracic aorta, the advantage of an endograft over open repair is even more apparent, as emergent surgery of the aortic arch and thoracoabdominal aneurysms often incur large incisions and extracorporeal bypass, with prohibitive risks of hemorrhage, stroke, renal impairment, and paraplegia. On the other hand a possible complication of stent placement in patients with chronic aortic dissection is the so-called luminal shift. It has been described in the literature [3] that arteries originating from the false lumen will be occluded after stent placement. In our patient collective we have not encountered this problem yet. Although the long-term durability of thoracic endografting remains unknown, there is evidence that the early results are at least comparable to those of surgery [5]. Vascular access is another determinant in technical success of the endovascular procedure and is sometimes difficult in an emergency situation. Stenosis, tortuosity, calcifications or in our case a chronic dissection of both iliac and femoral arteries can make the progression of a large introducer sheath very hazardous or even impossible. Especially in younger patients the right axillary artery should be considered as a possible access for antegrade stent placement [6]. On the other hand in small patients with narrow arteries or in older patients with arteriosclerosis and a more rigid arterial system it may be impossible to use the axillary artery for access because one of the major limitations is the design of thoracic stent grafts and the size of the introducer sheets. To accurately assess patients’ anatomy prior to treatment, it is crucial to obtain a contrast enhanced ECG gated MDCT. In comparison to other stent graft systems the advantage of the stent graft we used in this case was the small size of the introducer sheath (20 Fr), the design which allows you to deliver the stent retro as well as antegradely and the short length of the entire system. Many of the other systems are designed just for retrograde delivery and therefore not suitable for antegrade stent placement in an emergency setting. There has yet to be an optimal stent graft for the thoracic aorta, and indiscriminate usage with poor patient selection will lead to major potentially life-threatening complications. In the future, we will continue to expect evolution of better-designed stent grafts for the thoracic aorta; in particular, a more flexible device with a smaller profile and better delivery control for more accurate deployment. The cardiothoracic surgeon should be enthusiastic in exploring this new frontier and acquiring endovascular skills to offer a less invasive option for treating his patients.
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References
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Abstract
1. Introduction
