Hybrid procedure in a patient with symptomatic thoraco ...

Hybrid procedure in a patient with symptomatic thoraco-abdominal aneurysm and prior abdominal aorticreconstruction – case report

Tomasz Synowiec, Paweł Chęciński, Przemysław Samolewski, Wojciech Zieliński, Daniel Konik-Piński, Angelika Kuczmarska

Department of General and Vascular Surgery and Angiology, Poznan University of Medical Sciences, Poland

Videosurgery and Other Miniinvasive Techniques 2012; 7 (2): 132-136

DOI: 10.5114/wiitm.2011.26765

A b s t r a c t

Open repair of thoracoabdominal aortic aneurysm is connected with high mortality and morbidity. On the otherhand, endovascular treatment of thoraco-abdominal aneurysms, which started 10 years ago, reduced periopera-tive mortality and morbidity. However, it results in a high level of late complications. It seems that an interestingsolution to the problem is a hybrid procedure, which allows late complications to be reduced with acceptable lev-els of operative mortality and morbidity. This case report presents the use of a hybrid procedure in treatment ofsymptomatic thoraco-abdominal aneurysm in a patient with prior abdominal aortic reconstruction. In the firststage the patient underwent open revascularization of visceral vessels of the aorta. One week later a thoraco-abdominal stent-graft was implanted. The perioperative and postoperative period was uncomplicated. Twomonths after the second intervention the patient returned to work. Control imaging conducted 30 and 90 daysafter the procedure confirmed patency of all revascularized vessels and did not reveal any graft-related compli-cations. The hybrid procedure seems to be an interesting alternative for open and endovascular repair of thora-co-abdominal aneurysms because it combines the advantages of open and endovascular repair. It also gives anopportunity to perform the procedure within a reasonable period of time from diagnosis of symptomatic thora-co-abdominal aneurysm.

Key words: abdominal aortic aneurysm, endovascular aortic repair, thoraco-abdominal aneurysm, hybrid procedure,open aortic repair.

Case report

Address for correspondence

Tomasz Synowiec MD, Department of General and Vascular Surgery and Angiology, Poznan University of Medical Sciences, 34 Dojazd,

60-631 Poznan, Poland, phone/fax: +48 61 846 45 30, mobile phone: +48 606 292 602, e-mail: [email protected]

Videosurgery

Introduction

Thoracoabdominal aortic aneurysms representabout 7% of all aortic aneurysms. They are muchless common than are aneurysms of the abdominalaorta located below the renal arteries, but due totheir location require careful planning of the surgi-cal treatment. The common Crawford classificationis used to categorize thoracoabdominal aneurysmswith regard to the extent of aortic and branchinvolvement. Large and symptomatic thoracoab-

dominal aneurysms require surgical repair becauseof the possibility of rupture. The risk of rupture foran aneurysm with the diameter of 5 cm is 1% peryear, with the diameter of 6 cm it is 10.2%, and withthe diameter of 7 cm it exceeds 32.5%. The ruptureof thoracoabdominal aortic aneurysms is fatal inmost cases. Two techniques of aneurysm manage-ment prevail: classic open repair and endovasculartreatment. A hybrid procedure has been gaining inpopularity for some time now [1, 2].

132 Videosurgery and Other Miniinvasive Techniques 2012; 7/2

Case report

In December 2010, a 53-year-old patient wasadmitted to the Department of General and VascularSurgery and Angiology with epigastric pain radiatingto the back.

The patient had been treated due to arterialhypertension and ischaemic heart disease. In 2006the patient was operated on because of abdominalaortic aneurysm located below the renal arteries.A straight aorto-aortic prosthesis was implanted dur-ing the procedure. Angio-CT performed revealed class3 thoracoabdominal aortic aneurysm according to theCrawford classification (Figure 1). The aneurysmbegan in the thoracic aorta at the level of the 6th ver-tebra and extended to the aorto-aortic prosthesisimplanted earlier. It involved the origin of the coeliactrunk, superior mesenteric artery and renal arteries.The maximum transverse size of the aneurysm was9.6 cm × 8.7 cm (Figure 2). In the first stage bloodpressure was decreased to the maximum value of110/70 mmHg with nitroglycerine infusion andhypotensive drugs oral therapy. The ailments werereduced, but they did not resolve completely. Giventhe symptomatic character of the aneurysm and itssize, the patient required urgent surgical treatment.It was decided to use the hybrid technique (Figure 3).

Firstly, the patient underwent open revasculariza-tion of visceral vessels of aorta. A bifurcated, silver

prosthesis was attached to the previously implantedprosthesis. The right renal artery was anastomosedto the right branch of the prosthesis in an end-to-sidemanner and the further portion of the right prosthe-sis branch was attached to the coeliac trunk withend-to-end anastomoses. The left branch of the pros-thesis was attached to the left renal artery using end-to-end anastomosis. Additionally, another straightprosthesis was anastomosed to the left branch. Itwas also connected to the superior mesenteric arteryin an end-to-side manner (Figure 4). The procedurelasted for 3.5 h. Blood loss amounted to 1500 ml. Vas-cular anastomoses with renal arteries were techni-cally the most challenging due to arterial fragility anddeep location. Postoperative course was uncompli-cated. In the 2nd stage, 7 days following the openrepair, an aortic stent-graft was implanted (ValiantCaptiva, Medtronic). The left common femoral arterywas dissected and the right common femoral arterywas punctured percutaneously under local anaesthe-sia. The catheter was placed through the puncture forarteriography. The stent-graft was inserted via theincised femoral artery, and consisted of two elementsdue to the length of the managed aneurysm. The firstpart was anchored in the proximal, healthy portion ofthe aorta, the second was connected with the firstone and finished in the aorto-aortic prosthesis, justabove the silver prosthesis implanted for visceral ves-sels of the aorta (Figure 5). The length of the proce-

Figure 1. 3D reconstruction of the thoracoab-dominal aneurysm (angio-CT)

Figure 2. The maximum transverse size theaneurysm reached at the L1 level (angio-CT)

Hybrid procedure in a patient with symptomatic thoraco-abdominal aneurysm and prior abdominal aortic reconstruction – case report

133Videosurgery and Other Miniinvasive Techniques 2012; 7/2

dure was 1.5 h. Blood loss amounted to 300 ml. Theperi- and post-operative course was uncomplicated.The patient was released from the hospital on the 3rd

post-operative day. After 30 days, follow-up angio-CTwas performed and after 3 months angio-NMR of the

thoracoabdominal aorta. Both examinations provedtotal exclusion of the aneurysm from circulation.Both of them showed full patency of anastomoseswith the visceral vessels (Figure 6). Two months afterthe procedure the patient returned to work.

Figure 3. Plan of the hybrid procedure Figure 4. Intraoperative image of the first stageof the surgery. Implanted silver vascular pros-thesis used for revascularization of the visceralbranches visible in the operative field

Thoracoabdominalaneurysm

“Old” aorto-aortic prosthesis

Thoracoabdominalstent-graft

Figure 5. Endovascular implantation of the aor-tic stent-graft

Figure 6. Vascular reconstruction performed 3 months after the surgery (angio-NMR)

Anastomosiswith the coeliac

trunk

Stent-graft

Anastomosiswith the leftrenal artery

Anastomosiswith the rightrenal artery

“Old” aorto-aorticprosthesis

Anastomosiswith the superior

mesentericartery

Silver prosthesis forrevascularization of visceral vessels

of aorta



Discussion

Open management of thoracoabdominal aorticaneurysm is the oldest method of treatment. Thefirst repair of the thoracoabdominal aortic aneurysmwas performed by DeBakey using a homograft, andCrawford improved treatment with vascular prosthe-ses. This technique was and is widely employed [3, 4].However, it requires a specialized vascular centrewith experience in the management of the pathologyof such type.

In many cases these procedures are connectedwith the necessity of extracorporeal circulation asperforming a few anastomoses exceeds 20-30 min,the final time for visceral vessels closure. The highestmortality rate is observed in the peri- and post-oper-ative period (up to 30 days following the procedure).It is estimated at around 8-25%, the risk of spinalcord damage at 3-12% and renal failure at 5-18% [5-9].

Other significant complications include cardiovas-cular incidents and respiratory failure. Complicationsconnected with the performed anastomoses are rareand do not exceed 1-3%. Good long-term results arean undisputable advantage of the technique andcomplications connected with the implanted pros-thesis are rare. Before stent-grafts were introduced,the technique was the only solution to treat thora-coabdominal aortic aneurysms [10-12]. Endovasculartechniques opened new opportunities for thoracoab-dominal aneurysm management. In 1991 Parodidescribed the first use of a stent-graft to treatabdominal aortic aneurysm. Dak et al., on the otherhand, used a stent-graft to manage thoracicaneurysm [13]. Since then, the endovascular tech-nique has gained huge popularity. With the experi-ence and the development of equipment, themethod, initially used only for management ofabdominal aortic aneurysms located below renalarteries and thoracic aneurysms, has begun to beused for thoracoabdominal aortic aneurysms. Mostlybranched and sometimes fenestrated stent-graftsand chimney technique have been used for thosecases. It is necessary to remember, however, that therigorous classification of patients is the key to suc-cessful endoluminal treatment. The size of ananeurysm and its neck region, concurrent arterioscle-rosis obliterans and the relationship with the sur-rounding organs are the most significant factorsdetermining the possibility of the procedure. Due to

strict criteria, only 40-60% of patients qualify forendovascular treatment. Disregarding the criteriadramatically increases the risk of complications [14-16]. The main postulated advantage of theendovascular technique is the reduction of mortalityand peri- and postoperative complication rate. Themortality rate is estimated at 7-15%, spinal cord dam-age at 1-12%, renal failure at 4-12% [17]. The cost ofthe procedure and the long time required to preparea stent-graft (it is made on request) are the most cru-cial disadvantages of the method. Additionally, long-term complications connected with a stent-graft area major issue. Endoleaks, stent-graft migration andthrombosis in one of its branches are among themain long-term complications. Due to the lack oflarge series of patients, unequivocal data concerningthe number of complications are unavailable. Pub-lished single series report the necessity of a sec-ondary intervention in 20% of cases within a year.However, the available data from randomized trialsconcerning the number of long-term complications incases of stent-graft implantation in classic abdominalaortic aneurysms located below the renal arteriesshows that they amount to 20-44% in an 8-yearobservation period, which allows for the assumptionthat the number of these complications in cases ofmuch more complex thoracoabdominal stent-graftsmay be even higher [18]. In the present case, theauthors decided to combine the advantages of theclassic surgical procedure and endovascular treat-ment, avoiding some of the disadvantages of bothpresented methods by using the hybrid technique.For some time it has been very popular and in select-ed cases it produces better results than the previous-ly described techniques. Unfortunately, there are norandomized trials on hybrid techniques in thoracoab-dominal aneurysm treatment [19, 20]. The openrepair itself appeared to be risky due to the patient’sheavy overloads and the extent of the procedure. Onthe other hand, the endovascular technique wasunacceptable due to the urgency of the procedure, notime for stent-graft preparation and the risk ofnumerous long-term complications connected withthe stent-graft implantation. The hybrid proceduredid not require extracorporeal circulation and the clo-sure of the aorta. It is also worth mentioning that thetime of the visceral vessels’ closure is short as each ofthe endovascularized arteries is closed separatelywhen anastomoses are performed. Additionally, bothstages of the procedure can take place at an interval

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of a few days, which allows the patient to be stabi-lized if necessary. It also appears that the hybrid tech-nique may be especially useful for class 3, accordingto the Crawford classification of thoracoabdominalaneurysms, as it reduces the extent of the open sur-gery, limiting it to opening only one body cavity – theperitoneal cavity. All these factors decrease the riskof perioperative complications [4, 19, 21, 22]. Anasto-moses performed in the area of healthy visceral arter-ies are another big advantage of the method. In thecase of open repair, the Carrel’s patch anastomosisfrequently uses the aneurysmal artery; in otherwords, it utilizes the defective arterial wall. The short-ness of the procedure, contrary to an endovascularmethod, as preparation of a stent-graft is time-con-suming, in the case of a symptomatic thoracoab-dominal aneurysm, is another significant factor sup-porting the hybrid technique.

Conclusions

Uncomplicated peri- and post-operative period,and the performed follow-up examinations, whichdid not reveal any complications connected to theimplanted stent-graft and coeliac vessel prostheses,enable us to assume that the chosen method wasthe right one. It appears that a hybrid technique is aninteresting alternative for thoracoabdominal an -eurysm management due to the combined advan-tages of open and endovascular treatment and theshortness of the procedure.

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