Ann Thorac Surg 2015;99:1447–9
patients. Developing a clear reconstruction strategy is essential. In this patient, considerations included delivering an additional stent-graft to address both the type 3 endoleak and to move the anastomosis site proximally to facilitate hemostasis. Even the most serious proximal TEVAR complications can be safely managed with a wellplanned hybrid operation based on an understanding of the anatomy, pathologic features, and device construct, as well as a focused analysis of the preoperative imaging.
References
Thoracic Endovascular Aortic Repair After Iatrogenic Aortic Dissection and False Lumen Stent Grafting Claudia Schrimpf, MD, Omke E. Teebken, MD, and Mathias Wilhelmi, MD Division of Vascular- and Endovascular Surgery, Department of Cardiothoracic-, Transplantation-, and Vascular Surgery, Hannover Medical School, Hannover, Germany
Iatrogenic aortic dissections are a severe complication after thoracic endovascular aortic repair, and treatment guidelines do not exist. Herein, we report a patient who experienced an iatrogenic type B aortic dissection during elective thoracic endovascular aortic repair and suggest an interventional treatment option. (Ann Thorac Surg 2015;99:1447–9) Ó 2015 by The Society of Thoracic Surgeons Accepted for publication May 28, 2014. Address correspondence to Dr Schrimpf, Hannover Medical School, Department of Cardiothoracic-, Transplantation-, and Vascular Surgery, Division of Vascular- and Endovascular Surgery, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1447
T
horacic endovascular aortic repair (TEVAR) is a common treatment for aneurysms in the descending aorta that is carried out in primary care hospitals throughout Germany. A severe complication of TEVAR is the occurrence of an iatrogenic aortic dissection. The cause of the dissection is often unknown; nevertheless, it is likely that the dissection may need immediate treatment. The following case report broaches the issue of an iatrogenic aortic dissection during TEVAR, and not only provides a treatment option but also discusses possible periprocedural steps during which the dissection might have happened. A 68-year-old male patient with an asymptomatic descending aortic aneurysm (62 mm diameter) presented in another hospital for elective TEVAR (Fig 1A). Concomitant diseases comprised hypertension, chronic obstructive pulmonary disease (GOLD III-IV), nicotine abuse, and asymptomatic peripheral arterial disease. After gaining access over the right calcified femoral artery, 5,000 U of heparin was given. A sheath was introduced, and an angiography of the thoracoabdominal aorta was performed. A wire was introduced, and a new angiography to determine the distal landing zone was performed. Afterwards, a larger sheath (24F Gore DrySeal, W.L. Gore & Assoc, Flagstaff, AZ) was inserted. Because of difficulties advancing the sheath, an angioplasty of the iliac vessels was performed twice before the sheath was introduced into the aorta. Wires were switched to an extra-stiff guidewire, and a stent graft (Gore cTAG, diameter 40 mm) was inserted and unleashed, followed by balloon remodeling. The completion angiogram showed a newly developed aortic type B dissection with subtotal occlusion of the aorta starting at the left subclavian artery and ending at the proximal rim of the graft. Emergency therapy consisted of a balloon angioplasty using a left brachial approach, with the intention to push the stent graft and the dissection membrane to the vascular wall, but the attempt failed. The intervention was discontinued, and after closing the access site, the patient was delivered to the ward. The patient had reduced groin pulses and exhibited paresthesia of both legs. A computed tomography scan was performed after the patient experienced paraplegia and abdominal pain. It showed a partial occlusion of the thoracic aorta as well as graft misplacement within the aortic wall (Fig 1B). The patient was immediately transferred to our center. An initial blood draw revealed creatine kinase, 109 U/L; creatinine, 108 mmol/L; aspartate aminotransferase, 29U/L; alanine aminotransferase, 24 U/L; myoglobin, 336 mg/L; and lactate within normal range. We decided on an endovascular approach to reestablish the aortic lumen. In case the interventional approach should fail, the patient was brought to a fully equipped cardiothoracic operating room with heart-and-lung machine and x-ray imaging. Overall time between aortic occlusion and initiation of the emergency procedure was 5 hours. After an unsuccessful attempt to pass the stent graft through the femoral artery, an antegrade access through the right brachial artery was performed. The misplaced endograft was passed, and the wire (Glidewire Advantage 0.03500 ; Terumo, Somerset, NJ) was retrieved in the right common femoral artery. Using this wire as a guiding 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.05.101
FEATURE ARTICLES
1. Brozzi NA, Roselli EE. Endovascular therapy for thoracic aortic aneurysms: state of the art in 2012. Curr Treat Options Cardiovasc Med 2012;14:149–63. 2. Cheng D, Martin J, Shennib H, et al. Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease: a systematic review and meta-analysis of comparative studies. J Am Coll Cardiol 2010;55:986–1001. 3. Williams JB, Anderson ND, Bhattacharva SD, et al. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg 2012;55:1255–62. 4. Idrees J, Arafat A, Johnston DR, Svensson LG, Roselli EE. Repair of retrograde ascending dissection after descending stent grafting. J Thorac Cardiovasc Surg 2014;147:151–4. 5. Follis F, Filippone G, Stabile A, et al. Endovascular graft deployment in the false lumen of type B dissection. Interact Cardiovasc Thorac Surg 2010;10:597–9. 6. Zhang R, Kofidis T, Baus S, Klima U. Iatrogenic type A dissection after attempted stenting of a descending aortic aneurysm. Ann Thorac Surg 2006;82:1523–5. 7. Roselli EE, Abdel-Halim M, Johnston D, et al. Open aortic repair following prior thoracic endovascular aortic repair. Ann Thorac Surg 2014;97:750–6. 8. Lima B, Roselli EE, Soltesz EG, et al. Modified and “reverse” frozen elephant trunk repairs for extensive disease and complications after stent grafting. Ann Thorac Surg 2012;93:103–9.
CASE REPORT SCHRIMPF ET AL EMERGENT ENDOVASCULAR TREATMENT AFTER TEVAR
1448
CASE REPORT SCHRIMPF ET AL EMERGENT ENDOVASCULAR TREATMENT AFTER TEVAR
Ann Thorac Surg 2015;99:1447–9
FEATURE ARTICLES
Fig 1. Computed tomography angiograph showing the (A, top and bottom) thoracic aneurysm of the descending aorta, (B, top and bottom) the iatrogenic Stanford type B aortic dissection after false stent implantation, and (C, top and bottom) results after a salvage procedure with the compressed stent graft in the false lumen. A scan (D, top and bottom) taken 2.5 years after implantation shows the compressed primary endograft (arrows). Top panels show sagittal computed tomography angiograph images, and bottom panels show transversal computed tomography angiograph images.
structure, a pigtail catheter (pigtail Supertorque, 5F, 100 cm; Cordis, Bridgewater, NJ) was inserted from the groin. After placing this catheter in the aortic arch, the wire was removed from the brachial artery, and the pigtail was advanced into the ascending aorta. After angiography, a stiff guidewire (Lunderquist straight exchange, extra-stiff wire guide 0.03500 , 300 cm; Cook Medical, Bloomington, IN) was introduced, and the aortic lumen was reestablished using two stent grafts (Valiant Captivia 42 mm, length 169 mm, 219 mm; Medtronic, Minneapolis, MN; Fig 1C). The old endograft remained compressed within the aortic wall (Fig 1C). Femoral pulses were palpable again, and the paresthesia vanished instantaneously. A 2.5-year follow-up computed tomography scan showed a properly excluded aortic aneurysm with the old graft still compressed in the aortic wall and absence of stenosis (Fig 1D).
Comment This report describes the rare complication of an iatrogenic Stanford type B aortic dissection after TEVAR. Retrograde type A aortic dissections are recognized as a complication after TEVAR (incidence up to 2% [1]), associated with uncovered struts, radial force, ballooning, and extensive oversizing [2]. To our knowledge no case of an accidental placement of a stent graft into the aortic wall in the setting of an iatrogenic aortic dissection after TEVAR has been published. The incidence of an iatrogenic type B dissection after thoracic aortic stent graft repairs is approximately 1% to 2%, mostly related to excessive neck angulation or intramural hematoma within the landing zone [3]. Guidelines to manage iatrogenic type B dissections do not exist, but treatment is advised for prevention or relief of
life-threatening complications such as intractable pain or a rapidly expanding aortic diameter [4]. In the presented case, immediate surgical treatment was justified owing to development of paresthetic and later paraplegic symptoms. Furthermore, the case can be considered a surgical emergency because of the occurrence of the dissection in a previously aneurysmal aorta [4]. Here an interventional approach was favored, but backup personnel as well as equipment were in standby mode to convert into an open thoracic repair or an axillofemoral bypass if needed. Retrospectively, it remains unclear how the dissection developed. Several scenarios are imaginable: (1) The dissection occurred when changing guidewires without sufficient visual control; wires dislocated unintentionally and partially penetrated the aortic wall, causing the tear. (2) The aorta dissected during ballooning of the initially placed endograft, resulting in a local rip of the vascular wall and a dissection. (3) The dissection occurred during the percutaneous transluminal angioplasty of the common femoral artery owing to an unintentional dislocation of the stiff guidewire. (4) The aortic wall was penetrated when changing the sheaths. To prevent these complications, accurate preprocedural planning, endograft selection, and continued image control of all procedural steps is mandatory [5]. Furthermore, preprocedural and postprocedural angiographic controls have to be performed for quality—as well as safety— management reasons. This case demonstrates the necessity of thorough and continued imaging of every procedural step to prevent
Ann Thorac Surg 2015;99:1449–51
life-threatening complications. Furthermore, it highlights that TEVAR should be performed in specialized vascular centers with backup personnel and equipment (extracorporeal circulation) to deal with adverse events, allowing adequate treatment of evolving complications without significant delay.
CASE REPORT AFIFI ET AL IMPALED AORTA
1449
We describe an unusual case of aortic perforation by a vertebral osteophyte, complicated by a mycotic pseudoaneurysm, in a patient who underwent successful repair. To our knowledge, no similar case has been reported previously. (Ann Thorac Surg 2015;99:1449–51) Ó 2015 by The Society of Thoracic Surgeons
References
Impaled Aorta: A Rare Case of Aortic Perforation With a Vertebral Outgrowth Rana O. Afifi, MD, Harleen K. Sandhu, MD, MPH, Charles D. Fraser, III, MS, and Anthony L. Estrera, MD, FACS Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, and Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston, Texas
Accepted for publication June 2, 2014. Address correspondence to Dr Estrera, Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, 6400 Fannin St, Ste 2850, Houston, TX 77030; e-mail: anthony.l.estrera@uth. tmc.edu.
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
A
ortic pseudoaneurysm after spinal trauma or surgical procedures has been previously reported [1], but aortic injury secondary to penetrating vertebral osteophytes has seldom been reported. We present a unique case of ruptured mycotic pseudoaneurysm in the transverse aortic arch with concomitant superior vena cava (SVC) injury secondary to a penetrating cervical osteophyte. A 65-year-old woman presented with pain and stiffness of her neck and shoulders, hemoptysis, fever, and lethargy. Her medical history was significant for bilateral mastectomies for breast cancer and colon resection for colon cancer 20 years and 14 years previously, respectively. She received chemotherapy and radiation therapy to her abdomen only. Other medical problems included cardiomyopathy and congestive heart failure. Three months prior, the patient experienced an acute respiratory event with bacteremia and pleural effusion, which diagnosed as empyema. Thoracoscopy revealed a hemothorax. She was readmitted 2 days later with a recurrence of her pulmonary infection. Noncontrast computed tomography (CT) demonstrated an apical mediastinal mass with calcification. Ultrasonographic examination was suspicious for pseudoaneurysm. Blood cultures revealed methicillin-sensitive Staphylococcus aureus (MSSA). The patient was given antibiotics and transferred to our facility. On admission, CT of the chest confirmed the diagnosis of a pseudoaneurysm at the level of transverse arch measuring 7.9 cm in the anterior mediastinum (Fig 1A). She became hypotensive and experienced respiratory distress. She was immediately intubated and taken to the operating room for a suspected rupture of the mycotic aneurysm. The patient underwent a sternotomy under deep hypothermic circulatory arrest through a femoral–femoral bypass. Intraoperatively, a superior mediastinal hematoma was identified in association with a long calcification that appeared to have perforated both the thoracic aortic arch and the SVC (Fig 1B). On a review of previous roentgenographic and CT images, this calcification was identified as a spear-shaped osteophyte originating from the cervical vertebra and protruding into the superior mediastinum (Figs 1C, 1D). This osteophyte had pierced the aorta and the SVC in the area of the pseudoaneurysm. Intraoperative cultures revealed gram-positive cocci (MSSA on 3-day cultures), confirming the diagnosis of a mycotic aneurysm. The osteophyte was proximally resected, and the SVC and aortic wall defects were repaired with autologous and 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.06.089
FEATURE ARTICLES
1. Williams JB, Andersen ND, Bhattacharya SD, et al. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg 2012;55:1255–62. 2. Grabenw€ oger M, Alfonso F, Bachet J, et al, European Association for Cardio-Thoracic Surgery (EACTS); European Society of Cardiology (ESC); European Association of Percutaneous Cardiovascular Interventions (EAPCI). Thoracic endovascular aortic repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg 2012;42:17–24. 3. Januzzi JL, Sabatine MS, Eagle KA, et al, International Registry of Aortic Dissection Investigators. Iatrogenic aortic dissection. Am J Cardiol 2002;89:623–6. 4. Hiratzka LF, Bakris GL, Beckman JA, et al, American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American College of Radiology; American Stroke Association; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of Thoracic Surgeons; Society for Vascular Medicine. 2010 ACCF/ AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010;121:e266–369. 5. Fanelli F, Dake MD. Standard of practice for the endovascular treatment of thoracic aortic aneurysms and type B dissections. Cardiovasc Intervent Radiol 2009;32:849–60.
patients. Developing a clear reconstruction strategy is essential. In this patient, considerations included delivering an additional stent-graft to address both the type 3 endoleak and to move the anastomosis site proximally to facilitate hemostasis. Even the most serious proximal TEVAR complications can be safely managed with a wellplanned hybrid operation based on an understanding of the anatomy, pathologic features, and device construct, as well as a focused analysis of the preoperative imaging.
References
Thoracic Endovascular Aortic Repair After Iatrogenic Aortic Dissection and False Lumen Stent Grafting Claudia Schrimpf, MD, Omke E. Teebken, MD, and Mathias Wilhelmi, MD Division of Vascular- and Endovascular Surgery, Department of Cardiothoracic-, Transplantation-, and Vascular Surgery, Hannover Medical School, Hannover, Germany
Iatrogenic aortic dissections are a severe complication after thoracic endovascular aortic repair, and treatment guidelines do not exist. Herein, we report a patient who experienced an iatrogenic type B aortic dissection during elective thoracic endovascular aortic repair and suggest an interventional treatment option. (Ann Thorac Surg 2015;99:1447–9) Ó 2015 by The Society of Thoracic Surgeons Accepted for publication May 28, 2014. Address correspondence to Dr Schrimpf, Hannover Medical School, Department of Cardiothoracic-, Transplantation-, and Vascular Surgery, Division of Vascular- and Endovascular Surgery, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1447
T
horacic endovascular aortic repair (TEVAR) is a common treatment for aneurysms in the descending aorta that is carried out in primary care hospitals throughout Germany. A severe complication of TEVAR is the occurrence of an iatrogenic aortic dissection. The cause of the dissection is often unknown; nevertheless, it is likely that the dissection may need immediate treatment. The following case report broaches the issue of an iatrogenic aortic dissection during TEVAR, and not only provides a treatment option but also discusses possible periprocedural steps during which the dissection might have happened. A 68-year-old male patient with an asymptomatic descending aortic aneurysm (62 mm diameter) presented in another hospital for elective TEVAR (Fig 1A). Concomitant diseases comprised hypertension, chronic obstructive pulmonary disease (GOLD III-IV), nicotine abuse, and asymptomatic peripheral arterial disease. After gaining access over the right calcified femoral artery, 5,000 U of heparin was given. A sheath was introduced, and an angiography of the thoracoabdominal aorta was performed. A wire was introduced, and a new angiography to determine the distal landing zone was performed. Afterwards, a larger sheath (24F Gore DrySeal, W.L. Gore & Assoc, Flagstaff, AZ) was inserted. Because of difficulties advancing the sheath, an angioplasty of the iliac vessels was performed twice before the sheath was introduced into the aorta. Wires were switched to an extra-stiff guidewire, and a stent graft (Gore cTAG, diameter 40 mm) was inserted and unleashed, followed by balloon remodeling. The completion angiogram showed a newly developed aortic type B dissection with subtotal occlusion of the aorta starting at the left subclavian artery and ending at the proximal rim of the graft. Emergency therapy consisted of a balloon angioplasty using a left brachial approach, with the intention to push the stent graft and the dissection membrane to the vascular wall, but the attempt failed. The intervention was discontinued, and after closing the access site, the patient was delivered to the ward. The patient had reduced groin pulses and exhibited paresthesia of both legs. A computed tomography scan was performed after the patient experienced paraplegia and abdominal pain. It showed a partial occlusion of the thoracic aorta as well as graft misplacement within the aortic wall (Fig 1B). The patient was immediately transferred to our center. An initial blood draw revealed creatine kinase, 109 U/L; creatinine, 108 mmol/L; aspartate aminotransferase, 29U/L; alanine aminotransferase, 24 U/L; myoglobin, 336 mg/L; and lactate within normal range. We decided on an endovascular approach to reestablish the aortic lumen. In case the interventional approach should fail, the patient was brought to a fully equipped cardiothoracic operating room with heart-and-lung machine and x-ray imaging. Overall time between aortic occlusion and initiation of the emergency procedure was 5 hours. After an unsuccessful attempt to pass the stent graft through the femoral artery, an antegrade access through the right brachial artery was performed. The misplaced endograft was passed, and the wire (Glidewire Advantage 0.03500 ; Terumo, Somerset, NJ) was retrieved in the right common femoral artery. Using this wire as a guiding 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.05.101
FEATURE ARTICLES
1. Brozzi NA, Roselli EE. Endovascular therapy for thoracic aortic aneurysms: state of the art in 2012. Curr Treat Options Cardiovasc Med 2012;14:149–63. 2. Cheng D, Martin J, Shennib H, et al. Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease: a systematic review and meta-analysis of comparative studies. J Am Coll Cardiol 2010;55:986–1001. 3. Williams JB, Anderson ND, Bhattacharva SD, et al. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg 2012;55:1255–62. 4. Idrees J, Arafat A, Johnston DR, Svensson LG, Roselli EE. Repair of retrograde ascending dissection after descending stent grafting. J Thorac Cardiovasc Surg 2014;147:151–4. 5. Follis F, Filippone G, Stabile A, et al. Endovascular graft deployment in the false lumen of type B dissection. Interact Cardiovasc Thorac Surg 2010;10:597–9. 6. Zhang R, Kofidis T, Baus S, Klima U. Iatrogenic type A dissection after attempted stenting of a descending aortic aneurysm. Ann Thorac Surg 2006;82:1523–5. 7. Roselli EE, Abdel-Halim M, Johnston D, et al. Open aortic repair following prior thoracic endovascular aortic repair. Ann Thorac Surg 2014;97:750–6. 8. Lima B, Roselli EE, Soltesz EG, et al. Modified and “reverse” frozen elephant trunk repairs for extensive disease and complications after stent grafting. Ann Thorac Surg 2012;93:103–9.
CASE REPORT SCHRIMPF ET AL EMERGENT ENDOVASCULAR TREATMENT AFTER TEVAR
1448
CASE REPORT SCHRIMPF ET AL EMERGENT ENDOVASCULAR TREATMENT AFTER TEVAR
Ann Thorac Surg 2015;99:1447–9
FEATURE ARTICLES
Fig 1. Computed tomography angiograph showing the (A, top and bottom) thoracic aneurysm of the descending aorta, (B, top and bottom) the iatrogenic Stanford type B aortic dissection after false stent implantation, and (C, top and bottom) results after a salvage procedure with the compressed stent graft in the false lumen. A scan (D, top and bottom) taken 2.5 years after implantation shows the compressed primary endograft (arrows). Top panels show sagittal computed tomography angiograph images, and bottom panels show transversal computed tomography angiograph images.
structure, a pigtail catheter (pigtail Supertorque, 5F, 100 cm; Cordis, Bridgewater, NJ) was inserted from the groin. After placing this catheter in the aortic arch, the wire was removed from the brachial artery, and the pigtail was advanced into the ascending aorta. After angiography, a stiff guidewire (Lunderquist straight exchange, extra-stiff wire guide 0.03500 , 300 cm; Cook Medical, Bloomington, IN) was introduced, and the aortic lumen was reestablished using two stent grafts (Valiant Captivia 42 mm, length 169 mm, 219 mm; Medtronic, Minneapolis, MN; Fig 1C). The old endograft remained compressed within the aortic wall (Fig 1C). Femoral pulses were palpable again, and the paresthesia vanished instantaneously. A 2.5-year follow-up computed tomography scan showed a properly excluded aortic aneurysm with the old graft still compressed in the aortic wall and absence of stenosis (Fig 1D).
Comment This report describes the rare complication of an iatrogenic Stanford type B aortic dissection after TEVAR. Retrograde type A aortic dissections are recognized as a complication after TEVAR (incidence up to 2% [1]), associated with uncovered struts, radial force, ballooning, and extensive oversizing [2]. To our knowledge no case of an accidental placement of a stent graft into the aortic wall in the setting of an iatrogenic aortic dissection after TEVAR has been published. The incidence of an iatrogenic type B dissection after thoracic aortic stent graft repairs is approximately 1% to 2%, mostly related to excessive neck angulation or intramural hematoma within the landing zone [3]. Guidelines to manage iatrogenic type B dissections do not exist, but treatment is advised for prevention or relief of
life-threatening complications such as intractable pain or a rapidly expanding aortic diameter [4]. In the presented case, immediate surgical treatment was justified owing to development of paresthetic and later paraplegic symptoms. Furthermore, the case can be considered a surgical emergency because of the occurrence of the dissection in a previously aneurysmal aorta [4]. Here an interventional approach was favored, but backup personnel as well as equipment were in standby mode to convert into an open thoracic repair or an axillofemoral bypass if needed. Retrospectively, it remains unclear how the dissection developed. Several scenarios are imaginable: (1) The dissection occurred when changing guidewires without sufficient visual control; wires dislocated unintentionally and partially penetrated the aortic wall, causing the tear. (2) The aorta dissected during ballooning of the initially placed endograft, resulting in a local rip of the vascular wall and a dissection. (3) The dissection occurred during the percutaneous transluminal angioplasty of the common femoral artery owing to an unintentional dislocation of the stiff guidewire. (4) The aortic wall was penetrated when changing the sheaths. To prevent these complications, accurate preprocedural planning, endograft selection, and continued image control of all procedural steps is mandatory [5]. Furthermore, preprocedural and postprocedural angiographic controls have to be performed for quality—as well as safety— management reasons. This case demonstrates the necessity of thorough and continued imaging of every procedural step to prevent
Ann Thorac Surg 2015;99:1449–51
life-threatening complications. Furthermore, it highlights that TEVAR should be performed in specialized vascular centers with backup personnel and equipment (extracorporeal circulation) to deal with adverse events, allowing adequate treatment of evolving complications without significant delay.
CASE REPORT AFIFI ET AL IMPALED AORTA
1449
We describe an unusual case of aortic perforation by a vertebral osteophyte, complicated by a mycotic pseudoaneurysm, in a patient who underwent successful repair. To our knowledge, no similar case has been reported previously. (Ann Thorac Surg 2015;99:1449–51) Ó 2015 by The Society of Thoracic Surgeons
References
Impaled Aorta: A Rare Case of Aortic Perforation With a Vertebral Outgrowth Rana O. Afifi, MD, Harleen K. Sandhu, MD, MPH, Charles D. Fraser, III, MS, and Anthony L. Estrera, MD, FACS Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, and Memorial Hermann Heart & Vascular Institute, Texas Medical Center, Houston, Texas
Accepted for publication June 2, 2014. Address correspondence to Dr Estrera, Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, 6400 Fannin St, Ste 2850, Houston, TX 77030; e-mail: anthony.l.estrera@uth. tmc.edu.
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
A
ortic pseudoaneurysm after spinal trauma or surgical procedures has been previously reported [1], but aortic injury secondary to penetrating vertebral osteophytes has seldom been reported. We present a unique case of ruptured mycotic pseudoaneurysm in the transverse aortic arch with concomitant superior vena cava (SVC) injury secondary to a penetrating cervical osteophyte. A 65-year-old woman presented with pain and stiffness of her neck and shoulders, hemoptysis, fever, and lethargy. Her medical history was significant for bilateral mastectomies for breast cancer and colon resection for colon cancer 20 years and 14 years previously, respectively. She received chemotherapy and radiation therapy to her abdomen only. Other medical problems included cardiomyopathy and congestive heart failure. Three months prior, the patient experienced an acute respiratory event with bacteremia and pleural effusion, which diagnosed as empyema. Thoracoscopy revealed a hemothorax. She was readmitted 2 days later with a recurrence of her pulmonary infection. Noncontrast computed tomography (CT) demonstrated an apical mediastinal mass with calcification. Ultrasonographic examination was suspicious for pseudoaneurysm. Blood cultures revealed methicillin-sensitive Staphylococcus aureus (MSSA). The patient was given antibiotics and transferred to our facility. On admission, CT of the chest confirmed the diagnosis of a pseudoaneurysm at the level of transverse arch measuring 7.9 cm in the anterior mediastinum (Fig 1A). She became hypotensive and experienced respiratory distress. She was immediately intubated and taken to the operating room for a suspected rupture of the mycotic aneurysm. The patient underwent a sternotomy under deep hypothermic circulatory arrest through a femoral–femoral bypass. Intraoperatively, a superior mediastinal hematoma was identified in association with a long calcification that appeared to have perforated both the thoracic aortic arch and the SVC (Fig 1B). On a review of previous roentgenographic and CT images, this calcification was identified as a spear-shaped osteophyte originating from the cervical vertebra and protruding into the superior mediastinum (Figs 1C, 1D). This osteophyte had pierced the aorta and the SVC in the area of the pseudoaneurysm. Intraoperative cultures revealed gram-positive cocci (MSSA on 3-day cultures), confirming the diagnosis of a mycotic aneurysm. The osteophyte was proximally resected, and the SVC and aortic wall defects were repaired with autologous and 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.06.089
FEATURE ARTICLES
1. Williams JB, Andersen ND, Bhattacharya SD, et al. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg 2012;55:1255–62. 2. Grabenw€ oger M, Alfonso F, Bachet J, et al, European Association for Cardio-Thoracic Surgery (EACTS); European Society of Cardiology (ESC); European Association of Percutaneous Cardiovascular Interventions (EAPCI). Thoracic endovascular aortic repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg 2012;42:17–24. 3. Januzzi JL, Sabatine MS, Eagle KA, et al, International Registry of Aortic Dissection Investigators. Iatrogenic aortic dissection. Am J Cardiol 2002;89:623–6. 4. Hiratzka LF, Bakris GL, Beckman JA, et al, American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American College of Radiology; American Stroke Association; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of Thoracic Surgeons; Society for Vascular Medicine. 2010 ACCF/ AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010;121:e266–369. 5. Fanelli F, Dake MD. Standard of practice for the endovascular treatment of thoracic aortic aneurysms and type B dissections. Cardiovasc Intervent Radiol 2009;32:849–60.
