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Thoracic Endovascular Aortic Repair for Ruptured Descending Thoracic Aortic Aneurysm Tomoyuki Minami, M.D.,*,y Kiyotaka Imoto, M.D.,* Keiji Uchida, M.D.,* Norihisa Karube, M.D.,* Shota Yasuda, M.D.,* Tomoki Choh, M.D.,* Shinichi Suzuki, M.D.,z and Munetaka Masuda, M.D.z *Cardiovascular Center, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan; yCardiovascular Surgery, Yokohama Municipal Citizens Hospital, Yokohama, Kanagawa, Japan; and zDepartment of Surgery, Yokohama City University Hospital, Yokohama, Kanagawa, Japan ABSTRACT Background: We evaluated clinical outcomes of thoracic endovascular aortic repair (TEVAR) for ruptured descending thoracic aortic aneurysm (rDTAA). Methods: Twenty-three patients with rDTAA (mean age, 76.8 W 8.8 years) underwent TEVAR at our center between January 2008 and April 2013. Results: In twenty-three patients, five patients (21.7%) were in shock before surgery. Technical success was achieved in 21 patients. After TEVAR, retrograde Type A aortic dissection occurred in one patient, Type I endoleak in one patient, and Type II endoleak in three patients. The 30-day mortality rate was 4.3% (n = 1), and there were five in-hospital deaths (21.7%). Six patients (26.1%) developed cerebral complications and two patients suffered from paraplegia. In the late phase, four patients died because of the following aortic events: re-rupture in one patient, rupture of another untreated aneurysm in two patients, and esophageal perforation in one patient. Conclusions: TEVAR is associated with relatively low early morbidity and mortality and can be performed in older and high-risk patients. However, because aortic events during follow-up after TEVAR are not rare, we recommend close follow-up and application of early and aggressive reintervention. doi: 10.1111/jocs.12499
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Ruptured descending thoracic aortic aneurysm (rDTAA) is a rare but very serious cardiovascular condition.1 The conventional treatment for rDTAA is emergent open surgery, that is, resection and replacement of the ruptured aneurysm with an artificial graft, but this is associated with high mortality and morbidity.2–4 Thoracic endovascular aortic repair (TEVAR) has been used for the treatment of elective descending thoracic aortic aneurysm in stable cases. Currently, TEVAR has been introduced as a treatment for rDTAA.5–7 We retrospectively studied our clinical results of TEVAR for rDTAA.
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Tomoyuki Minami, M.D., Yokohama Municipal Citizen’s Hospital, Cardiovascular Surgery, Okazawa-cho 56, Hodogaya-ku, Yokohama, Kanagawa, 240-8555 Japan. Fax: 81-45-3325599; e-mail: [email protected]
METHODS Study population Institutional Review Board permission was not necessary to publish this article. TEVAR was introduced for the management of rDTAA in January 2008 at the Yokohama City University Medical Center, Japan. Since then, we have chosen TEVAR as the first-line treatment for rDTAA. Contraindications for endovascular repair include no proximal or distal aortic landing zone or an aortic diameter that is too wide for available stent grafts. Small common femoral arteries do not typically preclude endovascular repair because an iliac conduit or an abdominal aortic conduit can be used for vascular access in these patients. Fifty patients with rDTAA were admitted to Yokohama City University Medical Center between January 2008 and April 2013. Among them, 23 patients (mean age, 76.8 8.8 years; 65.2% men) were considered anatomically favorable for endovascular repair. These 23 patients underwent TEVAR and
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were enrolled in our study. Another 27 patients were not anatomically suitable for TEVAR and 13 patients underwent open surgery and 14 patients underwent conservative therapy. There were two in-hospital deaths (15.4%) in the open surgery group and ten inhospital deaths (71.4%) in the conservative therapy group (Fig. 1). We diagnosed the rupture according to the presence of extravasation around the aortic aneurysm and/or the presence of mediastinal hematoma on computed tomography (CT). Patients who presented with rupture of iatrogenic or traumatic origin, aortic dissection, or thoracoabdominal aortic aneurysm were excluded. Patients with pleural effusion alone without mediastinal hematoma were also excluded. Endovascular technique We performed brain, chest, and abdominal CT angiography in each patient before TEVAR. All interventions were guided by C-arm fluoroscopy and were performed by a cardiothoracic surgeon with the patient under general anesthesia. No patient underwent spinal drainage before TEVAR. Under guidance by transesophageal echocardiography, a curved, extra-stiff wire was placed in the ascending aorta from the common femoral artery, iliac artery, or abdominal aorta. In this series, we used the following four types of stent grafts: nonfenestrated handmade stent grafts comprising a Gianturco Z-stent (Cook, Inc., Bloomington, IN, USA) and a polyethylene terephthalate graft (UB
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WOVEN GRAFT, UBE JUNKEN Co., Ltd, Chiba, Japan); fenestrated handmade stent grafts comprising a stainless steel stent and an e-polytetrafluoroethylene graft; Gore1 TAG1 thoracic endoprosthesis (W.L. Gore and Associates, Flagstaff, AZ, USA); and ValiantTM thoracic stent grafts (Medtronic, Inc., Santa Rosa, CA, USA). Stent grafts with a larger diameter (equivalent to 110% to 120% of the native aortic landing zone diameter) were used depending on the findings in the preoperative CT. In some patients, it was necessary to occlude the left common carotid and left subclavian arteries to ensure the proximal landing zone. If necessary, right carotid artery to left carotid artery bypass and/or left carotid artery to left subclavian artery bypass and/or right subclavian artery to left subclavian artery bypass were performed before TEVAR. Procedural ‘‘technical’’ success was defined when the stent graft was accurately deployed and the aneurysm was excluded from the circulation (i.e., without Type I or III endoleaks8). Postdilatation of the proximal landing zone with an aortic balloon catheter was undertaken and angiography was performed to confirm the absence of endoleaks and dissection. After TEVAR, patients were admitted to the intensive care unit for further management. Follow-up and statistical analysis Data were obtained from medical records or by telephonic interviews. Follow-up CT was conducted one week after surgery and at least once a year after
Figure 1. Fifty patients with rDTAA were admitted to Yokohama City University Medical Center between January 2008 and April 2013. Among them, 23 patients, who were considered anatomically favorable for endovascular repair, underwent TEVAR. This flow chart shows the treatments and outcomes of the 23 patients. The other 27 patients were not anatomically suitable for TEVAR and 13 patients underwent open surgery and 14 patients underwent conservative therapy.
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discharge to evaluate the short- and mid-term outcomes. Aortic events were defined as: reinterventions related to the aorta, progression to acute Type A aortic dissection, dilatation of the aortic aneurysm, re-rupture, new endoleaks, and surgeries for infection associated with aortic disease. The follow-up rate was 95.7% (one patient was lost to follow-up). Data are expressed as means standard deviation. Time-related changes in freedom from aorta-related events and survival were analyzed using the Kaplan– Meier method. RESULTS Patients and surgeries
graft. Simple occlusion of the left subclavian artery was required to create a landing zone in nine patients, and in two patients, we performed occlusion of the left common carotid and subclavian arteries and a bypass from the right common carotid artery to the left. Occlusion of the left subclavian artery and bypass from the right axillary artery to the left was required in two patients (Table 2). Thirteen patients underwent open surgery for rDTAA and six (46.2%) exhibited shock before surgery. Open surgery was performed within 24 hours in 11 patients (84.6%), and the mean duration of surgery was 434 125 minutes. Early outcomes
Twenty-three patients underwent TEVAR for rDTAA. The maximum aortic aneurysm diameter at disease onset was 59.1 10 mm. Ten patients (43.5%) exhibited hemothorax. Of the 23 patients, five (21.7%) exhibited shock before surgery and among them, four developed tension hemothorax and one developed tension hemomediastinum after fluid resuscitation (Table 1). TEVAR was performed within 24 hours in 18 patients (78.3%), and the mean duration of surgery was 161 68 min. The common femoral artery was used for vascular access in eighten patients, iliac artery in three patients, and abdominal aorta in two patients. In the early phase of this study, the following handmade stent grafts were often used: nonfenestrated handmade stent grafts in three patients, fenestrated handmade stent grafts in three patients, Gore1 TAG1 Thoracic Endoprostheses in 16 patients, and ValiantTM Thoracic Stent Graft in one patient. In three patients, the proximal landing zone was Z0 and all three underwent TEVAR with a fenestrated handmade stent
TABLE 1 Baseline Clinical Characteristics
Age Gender, male Comorbidities Hypertension Hyperlipidemia Diabetes COPD CAD CKD Prior cardiac surgery Prior abdominal aortic intervention Prior thoracic aortic intervention Aneurysm diameter, mm Hemothorax Preoperative shock Tension hemothorax Tension hemomediastinum
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N or mean (N = 23)
% or WSD
76.8 15
8.8 65.2
13 1 1 3 3 2 1 4 4 59.1 10 5 4 1
56.5 4.3 4.3 13.0 13.0 8.7 4.3 17.4 17.4 10.0 43.5 21.7 17.4 4.3
CAD, coronary artery disease; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease. Preoperative shock means that one’s systolic blood pressure is less than 90 mmHg before surgery.
Figure 1 is the flow chart which shows the treatments and outcomes of the 23 patients (Fig. 1). Technical success was achieved in 21 patients. Type I endoleak was diagnosed after TEVAR in the first patient and endoleaks could not be diagnosed after TEVAR in the second patient. This patient exhibited shock before surgery and, after fluid resuscitation, she developed a tension hemomediastinum. CT revealed massive hematoma in the mediastinum, and the tension hemomediastinum had caused the left atrium to collapse (Fig. 2). She exhibited pulseless electrical activity after anesthesia and required cardiopulmonary resuscitation during TEVAR. After TEVAR, her blood pressure did not rise and angiography was not performed. She died soon after surgery. The 30-day mortality rate was 4.3% (n ¼ 1) and there were five in-hospital deaths (21.7%) including one operative death. Among the in-hospital deaths, one patient had a Type I endoleak after TEVAR. He underwent re-intervention with TEVAR, but suffered from severe cerebral infarct, respiratory failure, and renal failure. Finally, he developed multiorgan failure
TABLE 2 Perioperative Characteristics
TEVAR within 24 hours Operation time Vascular access Common femoral artery Common iliac artery Abdominal aorta Device Nonfenestrated handmade stent Fenestrated handmade stent Gore TAG Medtronic Valiant Proximal landing zone Zone 0 Zone 1 Zone 2 Zone 3 Zone 4 Procedure for left subclavian artery Simple occlusion Bypass and occlusion
N or mean (N = 23)
% or WSD
18 161
78.3 68
18 3 2
78.3 13.0 8.7
3 3 16 1
13.0 13.0 69.6 4.3
3 2 6 5 7
13.0 8.7 26.1 21.7 30.4
9 2
39.1 8.7
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Figure 2. Computed tomography revealing a ruptured descending thoracic aortic aneurysm, with massive hematoma in the mediastinum. Massive bleeding led to tension hemomediastinum, collapse of the left atrium, and restrictive abnormalities like cardiac tamponade. (*) collapse of the left atrium.
and died 60 days after admission. The other two inhospital death patients were in shock before surgery and they developed tension hemothorax after fluid resuscitation. They developed multiorgan failure after TEVAR and died 35 and 40 days after admission, respectively. The remainding in-hospital death patient developed paraplegia and esophageal perforation after TEVAR. He underwent transthoracic excision of the esophagus but developed sepsis and died 35 days after admission. Periprocedural cerebral complications occurred in six patients (26.1%) and postoperative paraplegia in two (8.7%). Seven patients (30.4%) developed pulmonary complications, one (4.3%) suffered from cardiac complication, two (8.7%) developed renal failure, and one (4.3%) had esophageal perforation. Retrograde Type A aortic dissection was diagnosed by postoperative CT in one patient of whom the proximal landing zone was Z0. She underwent open surgery successfully. Endoleaks were diagnosed in four patients (17.4%) after TEVAR and comprised a Type I endoleak in one patient and a Type II endoleak in three patients (Table 3).
TABLE 3 Early Postoperative Outcomes
Technical success 30-day mortality Hospital death Complications Cerebral complication Paraplegia Pulmonary complication Cardiac complication Renal failure Esophageal perforation Retrograde Type A dissection Endoleak Early reintervention for aorta
N = 23
%
21 1 5
91.3 4.3 21.7
6 2 7 1 2 1 1 4 4
26.1 8.7 30.4 4.3 8.7 4.3 4.3 17.4 17.4
We performed early reinterventions in the following four patients: one with esophageal perforation underwent transthoracic excision of the esophagus, one with retrograde Type A aortic dissection underwent open surgery, one with a Type I endoleak underwent a second TEVAR, and one with a Type II endoleak underwent coil embolization. Two other patients with Type II endoleaks were observed and did not undergo reintervention. Of the five patients who exhibited shock before surgery, three patients died during hospitalization. Finally, 12 patients were discharged to home and the other six patients were transferred to other extended care hospitals. In the open surgery group, the 30-day mortality rate was 7.7% (n ¼ 1) and there were two in-hospital deaths (15.4%). Periprocedural cerebral complications occurred in four patients (30.8%) and there were no postoperative paraplegia. Three (23.1%) patients underwent early reoperations: two were operations for mediastinitis and one was pacemaker implantation. Late outcomes The mean follow-up time of patients who were alive at 30 days was 15.8 13.2 months. In the late phase, none of the patients developed new endoleaks. However, there were five late deaths, four of which resulted from aortic events. One patient had a Type II endoleak after the first TEVAR. The aneurysm expanded during follow-up and we suggested that the patient have a reintervention. However, the patient refused re-intervention; the aneurysm re-ruptured and he died 333 days after the first TEVAR. Another patient died of sepsis resulting from an aortoesophageal fistula. Six months after the first TEVAR, he presented with fever. CT revealed a new aortoesophageal fistula and we performed several thoracotomy procedures. However, we could not control the sepsis and he died 14 months after the first TEVAR. In two patients, despite the disappearance of the descending thoracic aortic aneurysms that were treated, other untreated aneurysms ruptured and they died 1 and 3.5 years after the first TEVAR, respectively. Another late death was caused by aspiration pneumonia. In the late phase, reinterventions for aorta-related diseases were required in four patients. Of them, two patients also had other aneurysms. We performed a second TEVAR four months after the first TEVAR in one of these patients and open surgery five months after the first TEVAR in the other. A third patient had a Type II endoleak after the first TEVAR. The original aneurysm expanded during follow-up and he underwent sclerosing therapy at another hospital 19 months after the first TEVAR. The last patient, as previously mentioned, died of sepsis as a result of an aortoesophageal fistula, and underwent several thoracotomy procedures. Another patient suffered from dilatation of the treated aortic aneurysm without endoleak. He refused reintervention and was observed. The aorta-related event-free rate was 53.9% 11% at one year and 33.7% 13.4% at two years (Fig. 3).
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Figure 3. The aorta-related event-free rate of patients after thoracic endovascular aortic repair for a ruptured descending thoracic aortic aneurysm. The aorta-related event-free rate was 53.9% 11% at one year and 33.7% 13.4% at two years.
The aorta-related survival rate was 72.7% 9.6% at one year and 57.8% 12.2% at two years (Fig. 4). In the open surgery group, there were three late deaths, two of which resulted from aortic events. Late reinterventions for aorta-related diseases were required in two patients. DISCUSSION Ruptured descending thoracic aortic aneurysm remains a formidable clinical disease. In this setting, the conventional therapy is open repair, but outcomes following the open repair of rDTAA remain poor despite improvements in perioperative care. Several studies9–13 have reported that early mortality rates, in-hospital or 30-day, range from 20% to 50% following open repair. Recently, several investigators have reported successful outcomes with TEVAR for the ruptured thoracic aorta.5–7,14–19 Mitchell et al.5 reported an early mortality rate of 16% with emergency TEVAR for descending
Figure 4. The aorta-related survival rate of patients after thoracic endovascular aortic repair for a ruptured descending thoracic aortic aneurysm. The aorta-related survival rate was 72.7% 9.6% at one year and 57.8% 12.2% at two years.
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thoracic aorta involving traumatic origin in 44 patients. Patel et al.6 compared open surgery with endovascular repair for nontraumatic ruptured descending thoracic aorta in 69 patients and reported that early mortality was lower with endovascular repair (11.4%) than with open surgery (26.5%). The study, which examined only endovascular repair for rDTAA, cited a report by Jonker et al.7 described an early mortality rate of 18.4% in 87 patients at 7 centers. We introduced TEVAR for the management of rDTAA, acute Type B aortic dissection with rupture, ruptured infected thoracic aortic aneurysm, and ruptured traumatic thoracic aortic disruption at our center in 2008, and found the procedure to be very effective, with low mortality and morbidity. When a patient with a ruptured thoracic aorta arrives at our center, we perform whole-body CT scanning and examine the location of the rupture, size of the aorta, range of the hematoma, and vertebral artery type. Then, if possible anatomically, we perform TEVAR as the firstchoice treatment. If it is not possible to perform TEVAR, we perform conventional open surgery or conservative therapy. We previously evaluated TEVAR for acute Type B aortic dissection with rupture20 our findings suggested that early outcomes did not significantly differ between open surgery and TEVAR for acute Type B aortic dissection with rupture, although TEVAR had the advantage of being less invasive. Ruptured thoracic aorta can be caused by several disparate pathologies; therefore, in this study, we focused on rDTAA which were caused by atherosclerosis. Endovascular repair allows the rapid exclusion of a ruptured descending thoracic aortic aneurysm without cardiovascular bypass, aortic clamping, or thoracotomy. In this study, technical success with TEVAR was achieved in 91.3%, the 30-day mortality was 4.3%, and the in-hospital death rate was 21.7%. These results are acceptable compared with the results of open surgical repair in the literature. TEVAR for rDTAA is associated with residual hematoma in the thorax and mediastinum. Jonker et al.7 reported that hemothorax at presentation was a strong predictor of mortality. Hemothorax and hemomediastinum in patients with rDTAA develop into tension hemothorax and tension hemomediastinum if patients have significant bleeding. In addition to hemorrhagic shock, the former poses an obstructive abnormality, whereas the latter causes collapse of the left atrium and restrictive abnormalities such as cardiac tamponade. Tension hemothorax and tension hemomediastinum also cause ventilatory failure and esophageal perforation during the perioperative period.21–24 We experienced a patient who had esophageal perforation in the early phase and a patient who had aortoesophageal fistula in the late phase. We think that both were caused by the pressure of the aneurysm and/ or hematoma. In this study, four patients developed tension hemothorax and all had exhibited shock before surgery. Two patients died in the hospital and two survived, but one suffered from severe cerebral complication caused by hypoxemia. Hemorrhagic shock can be controlled by
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fluid resuscitation, but obstructive abnormalities caused by tension hemothorax cannot be controlled by fluid resuscitation. Thoracic drainage is the only way to improve obstructive abnormalities, even if drainage poses further bleeding. When tension hemothorax is diagnosed, it is necessary to perform thoracic drainage and control the intrathoracic pressure as soon as possible. After that, TEVAR must be performed with continuous blood transfusion and controlled bleeding from the drain. Tension hemomediastinum is a rare and critical pathology. One patient developed tension hemomediastinum in this study. Her CT revealed massive hematoma in the mediastinum and collapse of the left atrium (Fig. 2). She exhibited pulseless electrical activity after anesthesia and required cardiopulmonary resuscitation during TEVAR. However, after TEVAR, her blood pressure failed to rise and she died shortly after surgery. We believe that massive bleeding caused tension hemomediastinum, collapse of the left atrium, and restrictive abnormalities such as cardiac tamponade. Periprocedural cerebral complications occurred in six patients. In one patient, cerebral infarction occurred at the time of rupture. Two patients exhibited shock before surgery and they were exposed to hypoxia due to hypoventilation. Two patients underwent occlusion of the left subclavian artery that might have caused a cerebral embolism. On the other hand, paraplegia occurred in two patients in this study. There was no case that underwent spinal drainage before TEVAR because we had to use heparin during emergency TEVAR. We might consider spinal drainage after TEVAR for preventing paraplegia. In this study, simple occlusion of the left subclavian artery was required to create a landing zone in nine patients, and occlusion of the left subclavian artery and bypass from the right axillary artery to the left was required in two patients. The Society for Vascular Surgery Practice Guidelines25 recommend that revascularization should be individualized and addressed on the basis of anatomy, urgency, and availability of surgical expertise in patients who require urgent TEVAR for life-threatening acute aortic syndromes, where achievement of a proximal seal necessitates coverage of the left subclavian artery.25 We consider it important to classify vertebral artery variations. Patients with an interrupted right vertebral artery or left terminal posterior inferior cerebellar artery are at high risk of cerebellar infarction following simple occlusion of the left subclavian artery.26 In patients requiring urgent TEVAR for rDTAA where achievement of a proximal seal necessitates coverage of the left subclavian artery and possessing an interrupted right vertebral artery or left terminal posterior inferior cerebellar artery, we performed bypass to the left subclavian artery before TEVAR. In the early phase, endoleak occurred at a high rate and was diagnosed in four patients (17.4%) after TEVAR. Early reintervention is required for endoleaks, and we performed early reintervention in two patients. Conversely, aneurysms were expanded during followup in two other patients with residual Type II endoleaks,
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and the aneurysm re-ruptured in one patient. Ruptured adventitia is present within the aneurysms of patients with rDTAA, and a residual endoleak very easily facilitates re-rupture of the aneurysm. Open surgery should be performed in patients who are anatomically unsuitable for TEVAR to avoid endoleaks. If an endoleak is diagnosed after emergency TEVAR for rDTAA, early, aggressive re-intervention including open surgery should be undertaken. In the late phase, we experienced several aortic events associated with other untreated aneurysms. Reinterventions for other aneurysms were required in two patients, and other untreated aneurysms ruptured with a fatal outcome in two patients. In two patients who died as a result of the rupture of other aneurysms, these aneurysms had already been diagnosed before rupture, but the patients refused additional intervention because of advanced age. Study limitation Our study has several limitations. This is a retrospective clinical study, and the number of patients is small because of the low incidence of rDTAA. Despite this we believe that the introduction of TEVAR improved the management of rDTAA in the acute phase, even in older and high-risk patients. CONCLUSIONS Emergency TEVAR for rDTAA can stabilize these patients more rapidly than open surgery. However, TEVAR is associated with a relatively high rate of aortic events during follow-up. Therefore, after emergency life-saving TEVAR, close follow-up and early, aggressive re-intervention including open surgery are recommended. REFERENCES 1. Johansson G, Markstrom U, Swedenborg J: Ruptured thoracic aortic aneurysms: A study of incidence and mortality rates. J Vasc Surg 1995;21:985–988. 2. Schermerhorn ML, Giles KA, Hamdan AD, et al: Population-based outcomes of open descending thoracic aortic aneurysm repair. J Vasc Surg 2008;48:821–827. 3. Achneck HE, Rizzo JA, Tranquilli M, et al: Safety of thoracic aortic surgery in the present era. Ann Thorac Surg 2007;84:1180–1185. 4. Cambria RP, Clouse WD, Davison JK, et al: Thoracoabdominal aneurysm repair: Results with 337 operations performed over a 15-year interval. Ann Surg 2002;236: 471–479. 5. Mitchell ME, Rushton FW, Jr, Boland AB, et al: Emergency procedures on the descending thoracic aorta in the endovascular era. J Vasc Surg 2011;54:1298–1302. 6. Patel HJ, Williams DM, Upchurch GR, Jr, et al: A comparative analysis of open and endovascular repair for the ruptured descending thoracic aorta. J Vasc Surg 2009;50:1265–1270. 7. Jonker FH, Verhagen HJ, Lin PH, et al: Outcomes of endovascular repair of ruptured descending thoracic aortic aneurysms. Circulation 2010;121:2718–2723. 8. Grabenwo¨ger M, Alfonso F, Bachet J, et al: Thoracic endovascular aortic repair (TEVAR) for the treatment of
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Thoracic Endovascular Aortic Repair for Ruptured Descending Thoracic Aortic Aneurysm Tomoyuki Minami, M.D.,*,y Kiyotaka Imoto, M.D.,* Keiji Uchida, M.D.,* Norihisa Karube, M.D.,* Shota Yasuda, M.D.,* Tomoki Choh, M.D.,* Shinichi Suzuki, M.D.,z and Munetaka Masuda, M.D.z *Cardiovascular Center, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan; yCardiovascular Surgery, Yokohama Municipal Citizens Hospital, Yokohama, Kanagawa, Japan; and zDepartment of Surgery, Yokohama City University Hospital, Yokohama, Kanagawa, Japan ABSTRACT Background: We evaluated clinical outcomes of thoracic endovascular aortic repair (TEVAR) for ruptured descending thoracic aortic aneurysm (rDTAA). Methods: Twenty-three patients with rDTAA (mean age, 76.8 W 8.8 years) underwent TEVAR at our center between January 2008 and April 2013. Results: In twenty-three patients, five patients (21.7%) were in shock before surgery. Technical success was achieved in 21 patients. After TEVAR, retrograde Type A aortic dissection occurred in one patient, Type I endoleak in one patient, and Type II endoleak in three patients. The 30-day mortality rate was 4.3% (n = 1), and there were five in-hospital deaths (21.7%). Six patients (26.1%) developed cerebral complications and two patients suffered from paraplegia. In the late phase, four patients died because of the following aortic events: re-rupture in one patient, rupture of another untreated aneurysm in two patients, and esophageal perforation in one patient. Conclusions: TEVAR is associated with relatively low early morbidity and mortality and can be performed in older and high-risk patients. However, because aortic events during follow-up after TEVAR are not rare, we recommend close follow-up and application of early and aggressive reintervention. doi: 10.1111/jocs.12499
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Ruptured descending thoracic aortic aneurysm (rDTAA) is a rare but very serious cardiovascular condition.1 The conventional treatment for rDTAA is emergent open surgery, that is, resection and replacement of the ruptured aneurysm with an artificial graft, but this is associated with high mortality and morbidity.2–4 Thoracic endovascular aortic repair (TEVAR) has been used for the treatment of elective descending thoracic aortic aneurysm in stable cases. Currently, TEVAR has been introduced as a treatment for rDTAA.5–7 We retrospectively studied our clinical results of TEVAR for rDTAA.
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Tomoyuki Minami, M.D., Yokohama Municipal Citizen’s Hospital, Cardiovascular Surgery, Okazawa-cho 56, Hodogaya-ku, Yokohama, Kanagawa, 240-8555 Japan. Fax: 81-45-3325599; e-mail: [email protected]
METHODS Study population Institutional Review Board permission was not necessary to publish this article. TEVAR was introduced for the management of rDTAA in January 2008 at the Yokohama City University Medical Center, Japan. Since then, we have chosen TEVAR as the first-line treatment for rDTAA. Contraindications for endovascular repair include no proximal or distal aortic landing zone or an aortic diameter that is too wide for available stent grafts. Small common femoral arteries do not typically preclude endovascular repair because an iliac conduit or an abdominal aortic conduit can be used for vascular access in these patients. Fifty patients with rDTAA were admitted to Yokohama City University Medical Center between January 2008 and April 2013. Among them, 23 patients (mean age, 76.8 8.8 years; 65.2% men) were considered anatomically favorable for endovascular repair. These 23 patients underwent TEVAR and
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were enrolled in our study. Another 27 patients were not anatomically suitable for TEVAR and 13 patients underwent open surgery and 14 patients underwent conservative therapy. There were two in-hospital deaths (15.4%) in the open surgery group and ten inhospital deaths (71.4%) in the conservative therapy group (Fig. 1). We diagnosed the rupture according to the presence of extravasation around the aortic aneurysm and/or the presence of mediastinal hematoma on computed tomography (CT). Patients who presented with rupture of iatrogenic or traumatic origin, aortic dissection, or thoracoabdominal aortic aneurysm were excluded. Patients with pleural effusion alone without mediastinal hematoma were also excluded. Endovascular technique We performed brain, chest, and abdominal CT angiography in each patient before TEVAR. All interventions were guided by C-arm fluoroscopy and were performed by a cardiothoracic surgeon with the patient under general anesthesia. No patient underwent spinal drainage before TEVAR. Under guidance by transesophageal echocardiography, a curved, extra-stiff wire was placed in the ascending aorta from the common femoral artery, iliac artery, or abdominal aorta. In this series, we used the following four types of stent grafts: nonfenestrated handmade stent grafts comprising a Gianturco Z-stent (Cook, Inc., Bloomington, IN, USA) and a polyethylene terephthalate graft (UB
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WOVEN GRAFT, UBE JUNKEN Co., Ltd, Chiba, Japan); fenestrated handmade stent grafts comprising a stainless steel stent and an e-polytetrafluoroethylene graft; Gore1 TAG1 thoracic endoprosthesis (W.L. Gore and Associates, Flagstaff, AZ, USA); and ValiantTM thoracic stent grafts (Medtronic, Inc., Santa Rosa, CA, USA). Stent grafts with a larger diameter (equivalent to 110% to 120% of the native aortic landing zone diameter) were used depending on the findings in the preoperative CT. In some patients, it was necessary to occlude the left common carotid and left subclavian arteries to ensure the proximal landing zone. If necessary, right carotid artery to left carotid artery bypass and/or left carotid artery to left subclavian artery bypass and/or right subclavian artery to left subclavian artery bypass were performed before TEVAR. Procedural ‘‘technical’’ success was defined when the stent graft was accurately deployed and the aneurysm was excluded from the circulation (i.e., without Type I or III endoleaks8). Postdilatation of the proximal landing zone with an aortic balloon catheter was undertaken and angiography was performed to confirm the absence of endoleaks and dissection. After TEVAR, patients were admitted to the intensive care unit for further management. Follow-up and statistical analysis Data were obtained from medical records or by telephonic interviews. Follow-up CT was conducted one week after surgery and at least once a year after
Figure 1. Fifty patients with rDTAA were admitted to Yokohama City University Medical Center between January 2008 and April 2013. Among them, 23 patients, who were considered anatomically favorable for endovascular repair, underwent TEVAR. This flow chart shows the treatments and outcomes of the 23 patients. The other 27 patients were not anatomically suitable for TEVAR and 13 patients underwent open surgery and 14 patients underwent conservative therapy.
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discharge to evaluate the short- and mid-term outcomes. Aortic events were defined as: reinterventions related to the aorta, progression to acute Type A aortic dissection, dilatation of the aortic aneurysm, re-rupture, new endoleaks, and surgeries for infection associated with aortic disease. The follow-up rate was 95.7% (one patient was lost to follow-up). Data are expressed as means standard deviation. Time-related changes in freedom from aorta-related events and survival were analyzed using the Kaplan– Meier method. RESULTS Patients and surgeries
graft. Simple occlusion of the left subclavian artery was required to create a landing zone in nine patients, and in two patients, we performed occlusion of the left common carotid and subclavian arteries and a bypass from the right common carotid artery to the left. Occlusion of the left subclavian artery and bypass from the right axillary artery to the left was required in two patients (Table 2). Thirteen patients underwent open surgery for rDTAA and six (46.2%) exhibited shock before surgery. Open surgery was performed within 24 hours in 11 patients (84.6%), and the mean duration of surgery was 434 125 minutes. Early outcomes
Twenty-three patients underwent TEVAR for rDTAA. The maximum aortic aneurysm diameter at disease onset was 59.1 10 mm. Ten patients (43.5%) exhibited hemothorax. Of the 23 patients, five (21.7%) exhibited shock before surgery and among them, four developed tension hemothorax and one developed tension hemomediastinum after fluid resuscitation (Table 1). TEVAR was performed within 24 hours in 18 patients (78.3%), and the mean duration of surgery was 161 68 min. The common femoral artery was used for vascular access in eighten patients, iliac artery in three patients, and abdominal aorta in two patients. In the early phase of this study, the following handmade stent grafts were often used: nonfenestrated handmade stent grafts in three patients, fenestrated handmade stent grafts in three patients, Gore1 TAG1 Thoracic Endoprostheses in 16 patients, and ValiantTM Thoracic Stent Graft in one patient. In three patients, the proximal landing zone was Z0 and all three underwent TEVAR with a fenestrated handmade stent
TABLE 1 Baseline Clinical Characteristics
Age Gender, male Comorbidities Hypertension Hyperlipidemia Diabetes COPD CAD CKD Prior cardiac surgery Prior abdominal aortic intervention Prior thoracic aortic intervention Aneurysm diameter, mm Hemothorax Preoperative shock Tension hemothorax Tension hemomediastinum
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N or mean (N = 23)
% or WSD
76.8 15
8.8 65.2
13 1 1 3 3 2 1 4 4 59.1 10 5 4 1
56.5 4.3 4.3 13.0 13.0 8.7 4.3 17.4 17.4 10.0 43.5 21.7 17.4 4.3
CAD, coronary artery disease; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease. Preoperative shock means that one’s systolic blood pressure is less than 90 mmHg before surgery.
Figure 1 is the flow chart which shows the treatments and outcomes of the 23 patients (Fig. 1). Technical success was achieved in 21 patients. Type I endoleak was diagnosed after TEVAR in the first patient and endoleaks could not be diagnosed after TEVAR in the second patient. This patient exhibited shock before surgery and, after fluid resuscitation, she developed a tension hemomediastinum. CT revealed massive hematoma in the mediastinum, and the tension hemomediastinum had caused the left atrium to collapse (Fig. 2). She exhibited pulseless electrical activity after anesthesia and required cardiopulmonary resuscitation during TEVAR. After TEVAR, her blood pressure did not rise and angiography was not performed. She died soon after surgery. The 30-day mortality rate was 4.3% (n ¼ 1) and there were five in-hospital deaths (21.7%) including one operative death. Among the in-hospital deaths, one patient had a Type I endoleak after TEVAR. He underwent re-intervention with TEVAR, but suffered from severe cerebral infarct, respiratory failure, and renal failure. Finally, he developed multiorgan failure
TABLE 2 Perioperative Characteristics
TEVAR within 24 hours Operation time Vascular access Common femoral artery Common iliac artery Abdominal aorta Device Nonfenestrated handmade stent Fenestrated handmade stent Gore TAG Medtronic Valiant Proximal landing zone Zone 0 Zone 1 Zone 2 Zone 3 Zone 4 Procedure for left subclavian artery Simple occlusion Bypass and occlusion
N or mean (N = 23)
% or WSD
18 161
78.3 68
18 3 2
78.3 13.0 8.7
3 3 16 1
13.0 13.0 69.6 4.3
3 2 6 5 7
13.0 8.7 26.1 21.7 30.4
9 2
39.1 8.7
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Figure 2. Computed tomography revealing a ruptured descending thoracic aortic aneurysm, with massive hematoma in the mediastinum. Massive bleeding led to tension hemomediastinum, collapse of the left atrium, and restrictive abnormalities like cardiac tamponade. (*) collapse of the left atrium.
and died 60 days after admission. The other two inhospital death patients were in shock before surgery and they developed tension hemothorax after fluid resuscitation. They developed multiorgan failure after TEVAR and died 35 and 40 days after admission, respectively. The remainding in-hospital death patient developed paraplegia and esophageal perforation after TEVAR. He underwent transthoracic excision of the esophagus but developed sepsis and died 35 days after admission. Periprocedural cerebral complications occurred in six patients (26.1%) and postoperative paraplegia in two (8.7%). Seven patients (30.4%) developed pulmonary complications, one (4.3%) suffered from cardiac complication, two (8.7%) developed renal failure, and one (4.3%) had esophageal perforation. Retrograde Type A aortic dissection was diagnosed by postoperative CT in one patient of whom the proximal landing zone was Z0. She underwent open surgery successfully. Endoleaks were diagnosed in four patients (17.4%) after TEVAR and comprised a Type I endoleak in one patient and a Type II endoleak in three patients (Table 3).
TABLE 3 Early Postoperative Outcomes
Technical success 30-day mortality Hospital death Complications Cerebral complication Paraplegia Pulmonary complication Cardiac complication Renal failure Esophageal perforation Retrograde Type A dissection Endoleak Early reintervention for aorta
N = 23
%
21 1 5
91.3 4.3 21.7
6 2 7 1 2 1 1 4 4
26.1 8.7 30.4 4.3 8.7 4.3 4.3 17.4 17.4
We performed early reinterventions in the following four patients: one with esophageal perforation underwent transthoracic excision of the esophagus, one with retrograde Type A aortic dissection underwent open surgery, one with a Type I endoleak underwent a second TEVAR, and one with a Type II endoleak underwent coil embolization. Two other patients with Type II endoleaks were observed and did not undergo reintervention. Of the five patients who exhibited shock before surgery, three patients died during hospitalization. Finally, 12 patients were discharged to home and the other six patients were transferred to other extended care hospitals. In the open surgery group, the 30-day mortality rate was 7.7% (n ¼ 1) and there were two in-hospital deaths (15.4%). Periprocedural cerebral complications occurred in four patients (30.8%) and there were no postoperative paraplegia. Three (23.1%) patients underwent early reoperations: two were operations for mediastinitis and one was pacemaker implantation. Late outcomes The mean follow-up time of patients who were alive at 30 days was 15.8 13.2 months. In the late phase, none of the patients developed new endoleaks. However, there were five late deaths, four of which resulted from aortic events. One patient had a Type II endoleak after the first TEVAR. The aneurysm expanded during follow-up and we suggested that the patient have a reintervention. However, the patient refused re-intervention; the aneurysm re-ruptured and he died 333 days after the first TEVAR. Another patient died of sepsis resulting from an aortoesophageal fistula. Six months after the first TEVAR, he presented with fever. CT revealed a new aortoesophageal fistula and we performed several thoracotomy procedures. However, we could not control the sepsis and he died 14 months after the first TEVAR. In two patients, despite the disappearance of the descending thoracic aortic aneurysms that were treated, other untreated aneurysms ruptured and they died 1 and 3.5 years after the first TEVAR, respectively. Another late death was caused by aspiration pneumonia. In the late phase, reinterventions for aorta-related diseases were required in four patients. Of them, two patients also had other aneurysms. We performed a second TEVAR four months after the first TEVAR in one of these patients and open surgery five months after the first TEVAR in the other. A third patient had a Type II endoleak after the first TEVAR. The original aneurysm expanded during follow-up and he underwent sclerosing therapy at another hospital 19 months after the first TEVAR. The last patient, as previously mentioned, died of sepsis as a result of an aortoesophageal fistula, and underwent several thoracotomy procedures. Another patient suffered from dilatation of the treated aortic aneurysm without endoleak. He refused reintervention and was observed. The aorta-related event-free rate was 53.9% 11% at one year and 33.7% 13.4% at two years (Fig. 3).
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Figure 3. The aorta-related event-free rate of patients after thoracic endovascular aortic repair for a ruptured descending thoracic aortic aneurysm. The aorta-related event-free rate was 53.9% 11% at one year and 33.7% 13.4% at two years.
The aorta-related survival rate was 72.7% 9.6% at one year and 57.8% 12.2% at two years (Fig. 4). In the open surgery group, there were three late deaths, two of which resulted from aortic events. Late reinterventions for aorta-related diseases were required in two patients. DISCUSSION Ruptured descending thoracic aortic aneurysm remains a formidable clinical disease. In this setting, the conventional therapy is open repair, but outcomes following the open repair of rDTAA remain poor despite improvements in perioperative care. Several studies9–13 have reported that early mortality rates, in-hospital or 30-day, range from 20% to 50% following open repair. Recently, several investigators have reported successful outcomes with TEVAR for the ruptured thoracic aorta.5–7,14–19 Mitchell et al.5 reported an early mortality rate of 16% with emergency TEVAR for descending
Figure 4. The aorta-related survival rate of patients after thoracic endovascular aortic repair for a ruptured descending thoracic aortic aneurysm. The aorta-related survival rate was 72.7% 9.6% at one year and 57.8% 12.2% at two years.
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thoracic aorta involving traumatic origin in 44 patients. Patel et al.6 compared open surgery with endovascular repair for nontraumatic ruptured descending thoracic aorta in 69 patients and reported that early mortality was lower with endovascular repair (11.4%) than with open surgery (26.5%). The study, which examined only endovascular repair for rDTAA, cited a report by Jonker et al.7 described an early mortality rate of 18.4% in 87 patients at 7 centers. We introduced TEVAR for the management of rDTAA, acute Type B aortic dissection with rupture, ruptured infected thoracic aortic aneurysm, and ruptured traumatic thoracic aortic disruption at our center in 2008, and found the procedure to be very effective, with low mortality and morbidity. When a patient with a ruptured thoracic aorta arrives at our center, we perform whole-body CT scanning and examine the location of the rupture, size of the aorta, range of the hematoma, and vertebral artery type. Then, if possible anatomically, we perform TEVAR as the firstchoice treatment. If it is not possible to perform TEVAR, we perform conventional open surgery or conservative therapy. We previously evaluated TEVAR for acute Type B aortic dissection with rupture20 our findings suggested that early outcomes did not significantly differ between open surgery and TEVAR for acute Type B aortic dissection with rupture, although TEVAR had the advantage of being less invasive. Ruptured thoracic aorta can be caused by several disparate pathologies; therefore, in this study, we focused on rDTAA which were caused by atherosclerosis. Endovascular repair allows the rapid exclusion of a ruptured descending thoracic aortic aneurysm without cardiovascular bypass, aortic clamping, or thoracotomy. In this study, technical success with TEVAR was achieved in 91.3%, the 30-day mortality was 4.3%, and the in-hospital death rate was 21.7%. These results are acceptable compared with the results of open surgical repair in the literature. TEVAR for rDTAA is associated with residual hematoma in the thorax and mediastinum. Jonker et al.7 reported that hemothorax at presentation was a strong predictor of mortality. Hemothorax and hemomediastinum in patients with rDTAA develop into tension hemothorax and tension hemomediastinum if patients have significant bleeding. In addition to hemorrhagic shock, the former poses an obstructive abnormality, whereas the latter causes collapse of the left atrium and restrictive abnormalities such as cardiac tamponade. Tension hemothorax and tension hemomediastinum also cause ventilatory failure and esophageal perforation during the perioperative period.21–24 We experienced a patient who had esophageal perforation in the early phase and a patient who had aortoesophageal fistula in the late phase. We think that both were caused by the pressure of the aneurysm and/ or hematoma. In this study, four patients developed tension hemothorax and all had exhibited shock before surgery. Two patients died in the hospital and two survived, but one suffered from severe cerebral complication caused by hypoxemia. Hemorrhagic shock can be controlled by
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fluid resuscitation, but obstructive abnormalities caused by tension hemothorax cannot be controlled by fluid resuscitation. Thoracic drainage is the only way to improve obstructive abnormalities, even if drainage poses further bleeding. When tension hemothorax is diagnosed, it is necessary to perform thoracic drainage and control the intrathoracic pressure as soon as possible. After that, TEVAR must be performed with continuous blood transfusion and controlled bleeding from the drain. Tension hemomediastinum is a rare and critical pathology. One patient developed tension hemomediastinum in this study. Her CT revealed massive hematoma in the mediastinum and collapse of the left atrium (Fig. 2). She exhibited pulseless electrical activity after anesthesia and required cardiopulmonary resuscitation during TEVAR. However, after TEVAR, her blood pressure failed to rise and she died shortly after surgery. We believe that massive bleeding caused tension hemomediastinum, collapse of the left atrium, and restrictive abnormalities such as cardiac tamponade. Periprocedural cerebral complications occurred in six patients. In one patient, cerebral infarction occurred at the time of rupture. Two patients exhibited shock before surgery and they were exposed to hypoxia due to hypoventilation. Two patients underwent occlusion of the left subclavian artery that might have caused a cerebral embolism. On the other hand, paraplegia occurred in two patients in this study. There was no case that underwent spinal drainage before TEVAR because we had to use heparin during emergency TEVAR. We might consider spinal drainage after TEVAR for preventing paraplegia. In this study, simple occlusion of the left subclavian artery was required to create a landing zone in nine patients, and occlusion of the left subclavian artery and bypass from the right axillary artery to the left was required in two patients. The Society for Vascular Surgery Practice Guidelines25 recommend that revascularization should be individualized and addressed on the basis of anatomy, urgency, and availability of surgical expertise in patients who require urgent TEVAR for life-threatening acute aortic syndromes, where achievement of a proximal seal necessitates coverage of the left subclavian artery.25 We consider it important to classify vertebral artery variations. Patients with an interrupted right vertebral artery or left terminal posterior inferior cerebellar artery are at high risk of cerebellar infarction following simple occlusion of the left subclavian artery.26 In patients requiring urgent TEVAR for rDTAA where achievement of a proximal seal necessitates coverage of the left subclavian artery and possessing an interrupted right vertebral artery or left terminal posterior inferior cerebellar artery, we performed bypass to the left subclavian artery before TEVAR. In the early phase, endoleak occurred at a high rate and was diagnosed in four patients (17.4%) after TEVAR. Early reintervention is required for endoleaks, and we performed early reintervention in two patients. Conversely, aneurysms were expanded during followup in two other patients with residual Type II endoleaks,
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and the aneurysm re-ruptured in one patient. Ruptured adventitia is present within the aneurysms of patients with rDTAA, and a residual endoleak very easily facilitates re-rupture of the aneurysm. Open surgery should be performed in patients who are anatomically unsuitable for TEVAR to avoid endoleaks. If an endoleak is diagnosed after emergency TEVAR for rDTAA, early, aggressive re-intervention including open surgery should be undertaken. In the late phase, we experienced several aortic events associated with other untreated aneurysms. Reinterventions for other aneurysms were required in two patients, and other untreated aneurysms ruptured with a fatal outcome in two patients. In two patients who died as a result of the rupture of other aneurysms, these aneurysms had already been diagnosed before rupture, but the patients refused additional intervention because of advanced age. Study limitation Our study has several limitations. This is a retrospective clinical study, and the number of patients is small because of the low incidence of rDTAA. Despite this we believe that the introduction of TEVAR improved the management of rDTAA in the acute phase, even in older and high-risk patients. CONCLUSIONS Emergency TEVAR for rDTAA can stabilize these patients more rapidly than open surgery. However, TEVAR is associated with a relatively high rate of aortic events during follow-up. Therefore, after emergency life-saving TEVAR, close follow-up and early, aggressive re-intervention including open surgery are recommended. REFERENCES 1. Johansson G, Markstrom U, Swedenborg J: Ruptured thoracic aortic aneurysms: A study of incidence and mortality rates. J Vasc Surg 1995;21:985–988. 2. Schermerhorn ML, Giles KA, Hamdan AD, et al: Population-based outcomes of open descending thoracic aortic aneurysm repair. J Vasc Surg 2008;48:821–827. 3. Achneck HE, Rizzo JA, Tranquilli M, et al: Safety of thoracic aortic surgery in the present era. Ann Thorac Surg 2007;84:1180–1185. 4. Cambria RP, Clouse WD, Davison JK, et al: Thoracoabdominal aneurysm repair: Results with 337 operations performed over a 15-year interval. Ann Surg 2002;236: 471–479. 5. Mitchell ME, Rushton FW, Jr, Boland AB, et al: Emergency procedures on the descending thoracic aorta in the endovascular era. J Vasc Surg 2011;54:1298–1302. 6. Patel HJ, Williams DM, Upchurch GR, Jr, et al: A comparative analysis of open and endovascular repair for the ruptured descending thoracic aorta. J Vasc Surg 2009;50:1265–1270. 7. Jonker FH, Verhagen HJ, Lin PH, et al: Outcomes of endovascular repair of ruptured descending thoracic aortic aneurysms. Circulation 2010;121:2718–2723. 8. Grabenwo¨ger M, Alfonso F, Bachet J, et al: Thoracic endovascular aortic repair (TEVAR) for the treatment of
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