Cath Lab Digest

Abstract

Objective. To present a challenging case of a patient with contained ruptured aneurysm of her aortic arch as well as a saccular aneurysm of the descending thoracic aorta with a history of previously repaired abdominal aortic aneurysm. Methods. Technical considerations for the placement of the endograft required us to perform extra anatomic reconstruction in the form of a right carotid to left carotid artery bypass, and a left carotid to left subclavian artery bypass. This provided the 2 cm proximal landing zone required for endovascular repair of the arch aneurysm. A 34 x 34 x 115 mm Talent (Medtronic EndoVascular, Minneapolis, Minnesota) thoracic graft was used to exclude the arch aneurysm. In addition, a separate 32 x 32 x 48 mm Talent cuff graft was used to exclude the saccular aneurysm located in the descending thoracic aorta. The intervening native aorta was left untouched. Results. The patient recovered well with no evidence of paralysis. Conclusion. When planning the repair of an aortic aneurysm, consideration must be given not only to the ability to cover the aneurysm, but to the consequences of doing so. We feel that precautions should be taken to cover as little of the native aorta as possible to decrease the associated risk of paraplegia in patients whose abdominal aorta has been replaced.

VASCULAR DISEASE MANAGEMENT 2011;8:E113–E115

Clinical History

The patient is a 67-year-old African American female with a past medical history significant for chronic obstructing pulmonary disease, hypertension, and deep vein thrombosis with pulmonary embolism who was transferred to our institution for evaluation of repair of an aneurysm of the ascending aorta and transverse arch of the aorta. She had undergone an open repair of an acutely symptomatic abdominal aortic aneurysm 3 months prior. The patient was admitted to an outside facility due to severe flank pain; imaging at that time showed an acute increase in the size of her aortic arch to 7.4 x 6.7 cm. Repeat imaging at our institution showed the aneurysm to have further increased in size to 8 cm with surrounding hematoma; therefore, a diagnosis of contained rupture of the aneurysm was made (Figures 1 and 2). Preoperative angiogram demonstrated the 8 cm aortic arch aneurysm (Figure 3) as well as a second saccular aneurysm located in the mid thoracic aorta. Owing to the patient’s multiple comorbidities, the decision was made to repair the aneurysms endovascularly to prevent exsanguination and death.

Procedure

The proximal location of the arch aneurysm would require the proximal landing zone to be at the distal border of the innominate artery. This would provide the 2 cm of normal aorta as the fixation area for the endograph (Figure 4). This would cover the left common carotid artery as well as the subclavian artery; therefore, the first step in the repair of this aneurysm was a left carotid artery to left subclavian artery, left carotid artery to left carotid artery bypass (Figure 5). This was performed using a 10 mm Hemashield graft (Boston Scientific, Natick, Massachusetts). The proximal left carotid artery was ligated and the proximal left subclavian artery was occluded using Nester coils (Cook Medical, Bloomington, Indiana). Due to the patient’s multiple comorbidities, it was felt that a debranching procedure with median sternotomy would not be well tolerated.

Due to the small size of the external iliac artery, a 10 mm Hemashield graft was sewn into the distal right external iliac artery in order to allow for the graft device to be introduced into the aorta.

After a series of intra-operative measurements were done to confirm the preoperative planning, a 34 x 34 x 115 mm Talent thoracic proximal main graft (Medtronic EndoVascular) was appropriately oriented and deployed (Figures 5 and 6). It was then ballooned in place with a Reliant balloon (Cook Medical, Bloomington, Indiana).

Attention was then turned to a second saccular aneurysm located in the mid thoracic aorta. The native aorta measured about 28 mm at this site. In order to avoid covering excessive length of the descending thoracic aorta, a 32 x 32 x 48 mm Talent thoracic distal main extension endograft was used (Figure 7).

At the conclusion of the procedure, the decision was made to place a spinal drain based on the patient’s decreased level of alertness and inability to cooperate with physical exam evaluations of her extremities.