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J Thorac Cardiovasc Surg 2007;133:1639-1641
© 2007 The American Association for Thoracic Surgery
Brief Communication |
a Department of Cardiovascular Surgery, Montreal Heart Institute, and the Université de Montréal, Montreal, Quebec, Canada
b Department of Interventional Radiology, Montreal Heart Institute, and the Université de Montréal, Montreal, Quebec, Canada.
Received for publication October 25, 2006; revisions received December 15, 2006; accepted for publication January 5, 2007. * Address for reprints: Raymond Cartier, MD, Department of Cardiovascular Surgery, Montreal Heart Institute, 5000 Belanger St, Montreal, Quebec H1T 1C8, Canada. (Email: rc2910{at}aol.com).
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Endovascular procedures are new options for high-risk patients presenting with a pathologic condition of the descending thoracic aorta. We report the case of a patient who underwent stent grafting of the descending thoracic aorta to treat a symptomatic penetrating ulcer. Because a conventional femoral approach was impossible, an antegrade right axillary approach was used.
A 53-year-old man was referred to us with a progressing intramural hematoma associated with a penetrating aortic ulcer of the descending thoracic aorta (T7-T8 level; Figure 1, A-E). Despite optimal medical therapy, the patient remained symptomatic, and 3 consecutive computed tomographic (CT) scans performed at 1-week intervals confirmed the progression of the ulcer. Because of the patient’s chronic obstructive pulmonary disease, left ventricular dysfunction, and chronic occlusion of the infrarenal aorta (Figure 1, F), conventional open-chest surgery was judged to be prohibitive. Two different stent grafting strategies were considered. The first option was to proceed to a classic retrograde stent graft delivery after an aortobi-iliac bypass, and the second was to deliver the stent graft in an antegrade fashion through the right axillary artery approach. The patient did not complain of significant claudication and refused conventional abdominal surgery. Axillary and subclavian arteries were patent, with diameters ranging between 8.5 and 9 mm (Figure 1, G). The CT scan revealed no significant atheromatous lesions on the aortic arch, and hence the second option was selected. The procedure was performed after the patient underwent general anesthesia. Digital subtraction angiography and transesophageal echocardiographic guidance were used. Before stent positioning, an aortography was performed through the left brachial artery with a pigtail catheter (Cordis; Johnson & Johnson, Warren, NJ). After intravenous administration of 5000 IU of heparin, the right axillary artery was dissected out, and a 10-mm Dacron conduit was sutured in a terminolateral fashion. The 22F delivery system (Valiant Medtronic, Minneapolis, Minn) was introduced by the axillary conduit on a 260-cm-long superstiff guide wire (Back-Up Meier; Boston Scientific, Oakland, NJ; Figure 1, H and I). A Valiant prosthesis (Proximal Free Flow straight, 129 x 30 mm) was positioned at the level of the aortic ulcer and deployed under controlled hypotension. Control angiography (Figure 1, J) and transesophageal echocardiography demonstrated adequate coverage of the aortic ulcer and absence of endovascular leak. The proximal end of the Dacron conduit was left in place and simply sutured to achieve hemostasis. Except for a mild left pleural effusion, the postoperative course was uneventful, and the follow-up CT scan at 6 months showed complete thrombosis of the aortic ulcer.
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Endovascular management of pathologic conditions of the descending thoracic aorta has been reported to be a safe and efficient alternative to conventional open-chest surgery in high-risk patients.1
Our patient presented with the unusual combination of thoracic aortic intramural hematoma with a penetrating ulcer and occlusive disease of the infrarenal abdominal aorta, precluding the classical retrograde femoral approach for stent graft deployment. Despite optimal medical therapy, the patient remained symptomatic and the ulcer progressed, making the surgical option mandatory.2,3 Concomitant treatment of the abdominal aorta and the thoracic aortic ulcer was the primary surgical strategy of choice. Although less invasive, endovascular procedures still carry the risk of immediate or delayed paraplegia, especially when the T9-T12 aortic segment is covered by the stent graft or when the procedure is performed concomitantly with surgical correction of infrarenal aortic aneurysms. In the Stanford series (n = 103), paraplegia was reported in 2 patients having undergone simultaneous repair of abdominal and thoracic aneurysms and in a third patient having undergone prior aortic aneurysm repair years before.4,5 For these reasons, we considered combining infrarenal aortic surgery with stent grafting of the thoracic aorta, a situation that increases the risk of paraplegia.
On angiographic and Doppler investigation, both axillary arteries were patent, with diameters of greater than 8 mm, and no significant arch disease was documented, demonstrating the axillary approach to be a safe one.
The left axillary artery could have been a better choice than the right one by preventing the manipulation of the device close to the origin of the supra-aortic vessels, with potential risk for cerebral embolisms. In our patient the bilateral pigtails initially inserted through both brachial approaches showed the right axillary approach to be straighter. Direct cannulation of the artery did not seem to be a reasonable strategy because the arterial wall looked thin and fragile. The use of an end-to-side 10-mm Dacron conduit was believed to be a safer approach.
In conclusion, in cases in which the femoral approach is not suitable, the antegrade right axillary approach constitutes a safe and efficient alternative for stent grafting of the thoracic aorta, as long as the arch and axillary anatomy are favorable.
References
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