Case Study
Synchronous hybrid repair for ruptured aneurysm of bovine aortic arch
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(4) 443–445 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313513595 aan.sagepub.com
Sidharth Viswanathan1, Ajay Savlania1, Vivek Agrawal1, Shashidhar Kallapa Parameshwarappa1, Kapilamoorthy Tirur Raman2 and Unnikrishnan Madathipat1
Abstract Rupture of an aortic arch aneurysm is a life-threatening emergency with the risk of mortality escalating by the hour. We describe the successful hybrid repair of a ruptured bovine aortic arch aneurysm in a 75-year-old man, which involved aortic arch debranching by ascending aorta-bicarotid bypass followed by relining of the aortic lumen with a stent-graft. The procedure was not only lifesaving but also resulted in an active gentleman at 2-year follow-up. Considering the morbidity and mortality of open surgery using circulatory arrest, state-of-the-art synchronous hybrid repair seems to be an effective alternative for ruptured aortic arch aneurysms.
Keywords Aortic arch aneurysm, vascular prosthesis, arch debranching, aortic stent graft
Introduction Rupture of an aortic arch aneurysm is a life-threatening condition. The estimated 5-year risk of rupture of an aneurysm with a diameter of 4 to 5.9 cm is 16%, but it rises to 31% for aneurysms greater than 6 cm.1 Surgical repair was the only available modality of treatment until recently, and it was fraught with high perioperative morbidity and mortality, apart from being a technical challenge to the surgeon and requiring deep hypothermic total circulatory arrest.2 Since the first thoracic endovascular aortic stent graft repair was reported in 1994, the technique has revolutionized the treatment of thoracic aortic aneurysms. Although it is a rapidly evolving technology, complexity of the aortic arch and the need to preserve circulation to its great vessels, poses technical challenges that necessitate hybrid repair by open surgical debranching of the arch vessels followed by deployment of an aortic stent-graft to reline the aortic domain.
Case report A 75-year-old man, known to be hypertensive, had acute onset of severe chest pain and dyspnea. On examination, he was in respiratory distress with blood pressure of 90/70 mm Hg. Heart sounds were
normal but air entry was absent over the left hemithorax. All peripheral pulses were palpable. His hemogram showed hemoglobin of 5.4 gdL 1 while other laboratory parameters were normal. An electrocardiogram was normal. Chest radiograph showed opacity of the left hemithorax with a rightward shift of the mediastinum (Figure 1a). Chest computed tomography-angiography demonstrated an 8-cm fusiformsacciform aneurysm flush with the origin of innominate artery and a bovine arch configuration with rupture into the left hemithorax (Figure 1b, 1c). After initial resuscitation including blood transfusions, he underwent emergency hybrid thoracic endovascular aortic stent graft repair. Ascending aorta-bicarotid bypass using an 16 8-mm albumin-coated knitted polyester graft 1 Division of Vascular and Endovascular Surgery, Department of Cardiothoracic & Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India 2 Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
Corresponding author: Unnikrishnan Madathipat, MCh, Division of Vascular and Endovascular Surgery, Department of CTVS, SCTIMST, Trivandrum, Kerala, India. Email: [email protected]
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Figure 1. (a) Chest radiograph showing total opacification of the left hemithorax with mediastinal shift. (b) Coronal computed tomography depicting an aneurysm of the arch immediately after the innominate artery ostium. (c) Axial computed tomography showing rupture of the arch aneurysm and massive left hemothorax.
Figure 2. (a) Completed supraaortic debranching with ascending aorta-bicarotid bypass using a 16 8-mm inverted albumin-coated knitted polyester graft. (b) Computed tomography-angiogram, volume-rendered 3-dimensional image, at 2-year follow-up, showing patent bypass grafts and good stent-graft apposition with no endoleak, and the occluded left subclavian artery with retrograde filling from the left vertebral artery.
(Albograft; Edwards Lifesciences, SA, Nyon, Switzerland) was performed by end-to-side anastomosis of one graft limb to the right common carotid artery and end-to-end anastomosis of the other limb to the left common carotid artery in the neck, proximally dividing and suturing the innominate artery in the mediastinum and the left common carotid artery in the neck (Figure 2a). Utmost care was taken to avoid breaching the left pleura during the procedure. This was followed by deployment of a 34 34 167-mm Valiant Thoracic Captiva aortic stent-graft (Medtronic, Inc., Minneapolis, MN, USA) from the distal ascending to the upper descending thoracic aorta across the arch, intentionally occluding the left
subclavian artery ostium without ischemic sequelae. Postoperatively, a left intercostal drainage tube was placed 24 h later to drain the hemorrhagic pleural effusion over the next 3 days. A tracheostomy was required on the 4th postoperative day to facilitate respiratory function and wean the patient off mechanical ventilation. He made a gradual recovery thereafter, and was discharged from hospital on the 15th postoperative day. On regular follow-up, he has been reviewed at 3 months, 9 months, and 2 years after discharge. Follow-up computed tomographyangiography at 2 years showed patent bypass grafts and good stent-graft apposition with no endoleak (Figure 2b).
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Discussion The reported incidence of thoracic aortic aneurysms is 10.4 per 100,000 persons per year, and it has recently shown an increasing trend.1The most dreaded complication is rupture, ending fatally if not treated expeditiously. Bovine arch configuration, once considered a benign anatomical variant, has of late been correlated with the increased preponderance of thoracic aortic disease.3 Surgical repair is associated with high rates of periprocedural mortality (7%–17%) and neurological complications (4%–12%).2 Considering the rapidity in executing the repair and the less invasive approach, endovascular techniques are now emerging as the preferred choice for thoracic aortic aneurysms, more so in the setting of rupture.4 Proper selection of the landing zone with a minimum of 20 mm, or better still 30 mm, of the proximal sealing zone, proximal to the aneurysm, often warrants coverage of the appropriate brachiocephalic arteries for safe fixation of the endograft. Intentional coverage of the left subclavian artery carries a low risk, according to clinical experience, except in the specific instances of stenosis or abnormalities of the supraaortic and intracranial arteries or when the entire descending thoracic aorta needs to be relined.5 Accurate and secure deployment in the arch becomes more challenging owing to the wide variability in arch configurations.6 More particularly, because of the drag force observed within a tube with strongly curved geometry in the presence of high blood flow and substantial movement of the arch with each heartbeat, the long-term outcome of endovascular prostheses in the arch has yet to be documented, thus substantiating the need for generous proximal sealing. In this case, the huge aneurysm originating in mid arch flush with the origin of the innominate artery mandated revascularization of both carotids through a median sternotomy, using a bifurcated graft from the ascending aorta. Total endovascular repair of an arch aneurysm using a fenestrated stent graft needs accurate and customized designing, which would have delayed treatment and hampered the opportunity to salvage our patient’s life in the emergency setting of rupture. The role of the chimney technique is still unclear, and long-
term endograft durability and proximal fixation remain significant concerns.7 However, hybrid endovascular repair has the potential to reduce operative morbidity and mortality in high-risk patients, compared to the standard surgical total arch replacement technique, by facilitating an extended secure proximal sealing zone, and avoiding prolonged circulatory arrest and profound hypothermia, and might not be inferior to open surgical procedures in terms of long-term durability. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Clouse WD, Hallett JW Jr, Schaff HV, Gayari MM, Ilstrup DM, Melton LJ and 3rd. Improved prognosis of thoracic aortic aneurysm: a population-based study. JAMA 1998; 280: 1926–1929. 2. Harrington DK, Walzer AS, Kaukuntla H, et al. Selective antegrade cerebral perfusion attenuates brain metabolic deficit in aortic arch surgery: a prospective randomized trial. Circulation 2004; 110(Suppl I): 1231–1236. 3. Hornick M, Moomiaie R, Mojibian H, et al. ‘Bovine’ aortic arch – a marker for thoracic aortic disease. Cardiology 2012; 123: 116–124. 4. Jonker FH, Trimarchi S, Verhagen HJ, Moll FL, Sumpio BE and Muhs BE. Meta-analysis of open versus endovascular repair for ruptured descending thoracic aortic aneurysm. J Vasc Surg 2010; 51: 1026–1032. 5. Kotelis D, Geisbu¨sch P, Hinz U, et al. Short and mid-term results after left subclavian artery coverage during endovascular repair of the thoracic aorta. J Vasc Surg 2009; 50: 1285–1292. 6. Peixuan Chiu, Heow Pueh Lee, Sudhakar K, Venkatesh and Pei Ho. Anatomical characteristics of the thoracic aortic arch in an Asian population. Asian Cardiovasc Thorac Ann 2013; 21: 151–159. 7. Moulakakis KG, Mylonas SN, Avgerinos E, et al. The chimney graft technique for preserving visceral vessels during endovascular treatment of aortic pathologies. J Vasc Surg 2012; 55: 1497–1503.
Downloaded from aan.sagepub.com by guest on November 16, 2015
Synchronous hybrid repair for ruptured aneurysm of bovine aortic arch
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(4) 443–445 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313513595 aan.sagepub.com
Sidharth Viswanathan1, Ajay Savlania1, Vivek Agrawal1, Shashidhar Kallapa Parameshwarappa1, Kapilamoorthy Tirur Raman2 and Unnikrishnan Madathipat1
Abstract Rupture of an aortic arch aneurysm is a life-threatening emergency with the risk of mortality escalating by the hour. We describe the successful hybrid repair of a ruptured bovine aortic arch aneurysm in a 75-year-old man, which involved aortic arch debranching by ascending aorta-bicarotid bypass followed by relining of the aortic lumen with a stent-graft. The procedure was not only lifesaving but also resulted in an active gentleman at 2-year follow-up. Considering the morbidity and mortality of open surgery using circulatory arrest, state-of-the-art synchronous hybrid repair seems to be an effective alternative for ruptured aortic arch aneurysms.
Keywords Aortic arch aneurysm, vascular prosthesis, arch debranching, aortic stent graft
Introduction Rupture of an aortic arch aneurysm is a life-threatening condition. The estimated 5-year risk of rupture of an aneurysm with a diameter of 4 to 5.9 cm is 16%, but it rises to 31% for aneurysms greater than 6 cm.1 Surgical repair was the only available modality of treatment until recently, and it was fraught with high perioperative morbidity and mortality, apart from being a technical challenge to the surgeon and requiring deep hypothermic total circulatory arrest.2 Since the first thoracic endovascular aortic stent graft repair was reported in 1994, the technique has revolutionized the treatment of thoracic aortic aneurysms. Although it is a rapidly evolving technology, complexity of the aortic arch and the need to preserve circulation to its great vessels, poses technical challenges that necessitate hybrid repair by open surgical debranching of the arch vessels followed by deployment of an aortic stent-graft to reline the aortic domain.
Case report A 75-year-old man, known to be hypertensive, had acute onset of severe chest pain and dyspnea. On examination, he was in respiratory distress with blood pressure of 90/70 mm Hg. Heart sounds were
normal but air entry was absent over the left hemithorax. All peripheral pulses were palpable. His hemogram showed hemoglobin of 5.4 gdL 1 while other laboratory parameters were normal. An electrocardiogram was normal. Chest radiograph showed opacity of the left hemithorax with a rightward shift of the mediastinum (Figure 1a). Chest computed tomography-angiography demonstrated an 8-cm fusiformsacciform aneurysm flush with the origin of innominate artery and a bovine arch configuration with rupture into the left hemithorax (Figure 1b, 1c). After initial resuscitation including blood transfusions, he underwent emergency hybrid thoracic endovascular aortic stent graft repair. Ascending aorta-bicarotid bypass using an 16 8-mm albumin-coated knitted polyester graft 1 Division of Vascular and Endovascular Surgery, Department of Cardiothoracic & Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India 2 Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
Corresponding author: Unnikrishnan Madathipat, MCh, Division of Vascular and Endovascular Surgery, Department of CTVS, SCTIMST, Trivandrum, Kerala, India. Email: [email protected]
Downloaded from aan.sagepub.com by guest on November 16, 2015
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Figure 1. (a) Chest radiograph showing total opacification of the left hemithorax with mediastinal shift. (b) Coronal computed tomography depicting an aneurysm of the arch immediately after the innominate artery ostium. (c) Axial computed tomography showing rupture of the arch aneurysm and massive left hemothorax.
Figure 2. (a) Completed supraaortic debranching with ascending aorta-bicarotid bypass using a 16 8-mm inverted albumin-coated knitted polyester graft. (b) Computed tomography-angiogram, volume-rendered 3-dimensional image, at 2-year follow-up, showing patent bypass grafts and good stent-graft apposition with no endoleak, and the occluded left subclavian artery with retrograde filling from the left vertebral artery.
(Albograft; Edwards Lifesciences, SA, Nyon, Switzerland) was performed by end-to-side anastomosis of one graft limb to the right common carotid artery and end-to-end anastomosis of the other limb to the left common carotid artery in the neck, proximally dividing and suturing the innominate artery in the mediastinum and the left common carotid artery in the neck (Figure 2a). Utmost care was taken to avoid breaching the left pleura during the procedure. This was followed by deployment of a 34 34 167-mm Valiant Thoracic Captiva aortic stent-graft (Medtronic, Inc., Minneapolis, MN, USA) from the distal ascending to the upper descending thoracic aorta across the arch, intentionally occluding the left
subclavian artery ostium without ischemic sequelae. Postoperatively, a left intercostal drainage tube was placed 24 h later to drain the hemorrhagic pleural effusion over the next 3 days. A tracheostomy was required on the 4th postoperative day to facilitate respiratory function and wean the patient off mechanical ventilation. He made a gradual recovery thereafter, and was discharged from hospital on the 15th postoperative day. On regular follow-up, he has been reviewed at 3 months, 9 months, and 2 years after discharge. Follow-up computed tomographyangiography at 2 years showed patent bypass grafts and good stent-graft apposition with no endoleak (Figure 2b).
Downloaded from aan.sagepub.com by guest on November 16, 2015
Viswanathan et al.
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Discussion The reported incidence of thoracic aortic aneurysms is 10.4 per 100,000 persons per year, and it has recently shown an increasing trend.1The most dreaded complication is rupture, ending fatally if not treated expeditiously. Bovine arch configuration, once considered a benign anatomical variant, has of late been correlated with the increased preponderance of thoracic aortic disease.3 Surgical repair is associated with high rates of periprocedural mortality (7%–17%) and neurological complications (4%–12%).2 Considering the rapidity in executing the repair and the less invasive approach, endovascular techniques are now emerging as the preferred choice for thoracic aortic aneurysms, more so in the setting of rupture.4 Proper selection of the landing zone with a minimum of 20 mm, or better still 30 mm, of the proximal sealing zone, proximal to the aneurysm, often warrants coverage of the appropriate brachiocephalic arteries for safe fixation of the endograft. Intentional coverage of the left subclavian artery carries a low risk, according to clinical experience, except in the specific instances of stenosis or abnormalities of the supraaortic and intracranial arteries or when the entire descending thoracic aorta needs to be relined.5 Accurate and secure deployment in the arch becomes more challenging owing to the wide variability in arch configurations.6 More particularly, because of the drag force observed within a tube with strongly curved geometry in the presence of high blood flow and substantial movement of the arch with each heartbeat, the long-term outcome of endovascular prostheses in the arch has yet to be documented, thus substantiating the need for generous proximal sealing. In this case, the huge aneurysm originating in mid arch flush with the origin of the innominate artery mandated revascularization of both carotids through a median sternotomy, using a bifurcated graft from the ascending aorta. Total endovascular repair of an arch aneurysm using a fenestrated stent graft needs accurate and customized designing, which would have delayed treatment and hampered the opportunity to salvage our patient’s life in the emergency setting of rupture. The role of the chimney technique is still unclear, and long-
term endograft durability and proximal fixation remain significant concerns.7 However, hybrid endovascular repair has the potential to reduce operative morbidity and mortality in high-risk patients, compared to the standard surgical total arch replacement technique, by facilitating an extended secure proximal sealing zone, and avoiding prolonged circulatory arrest and profound hypothermia, and might not be inferior to open surgical procedures in terms of long-term durability. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Clouse WD, Hallett JW Jr, Schaff HV, Gayari MM, Ilstrup DM, Melton LJ and 3rd. Improved prognosis of thoracic aortic aneurysm: a population-based study. JAMA 1998; 280: 1926–1929. 2. Harrington DK, Walzer AS, Kaukuntla H, et al. Selective antegrade cerebral perfusion attenuates brain metabolic deficit in aortic arch surgery: a prospective randomized trial. Circulation 2004; 110(Suppl I): 1231–1236. 3. Hornick M, Moomiaie R, Mojibian H, et al. ‘Bovine’ aortic arch – a marker for thoracic aortic disease. Cardiology 2012; 123: 116–124. 4. Jonker FH, Trimarchi S, Verhagen HJ, Moll FL, Sumpio BE and Muhs BE. Meta-analysis of open versus endovascular repair for ruptured descending thoracic aortic aneurysm. J Vasc Surg 2010; 51: 1026–1032. 5. Kotelis D, Geisbu¨sch P, Hinz U, et al. Short and mid-term results after left subclavian artery coverage during endovascular repair of the thoracic aorta. J Vasc Surg 2009; 50: 1285–1292. 6. Peixuan Chiu, Heow Pueh Lee, Sudhakar K, Venkatesh and Pei Ho. Anatomical characteristics of the thoracic aortic arch in an Asian population. Asian Cardiovasc Thorac Ann 2013; 21: 151–159. 7. Moulakakis KG, Mylonas SN, Avgerinos E, et al. The chimney graft technique for preserving visceral vessels during endovascular treatment of aortic pathologies. J Vasc Surg 2012; 55: 1497–1503.
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