Endovascular repair after stent elephant trunk procedure for extensive thoracic aortic aneurysm

Interactive CardioVascular and Thoracic Surgery, Dec 2008

Hybrid surgical-endovascular procedure was conducted in a 46-year-old male with extensive thoracic aortic aneurysm. Ascending aorta and arch replacement combined with stent elephant trunk implantation was performed first. An open stent-graft was implanted into the descending aorta. One month later, endovascular repair was conducted. Postoperative CTA showed total coverage of the descending aorta by stent-grafts and the descending aortic aneurysm was totally thrombo-excluded. Stent elephant trunk may be a better alternative to conventional elephant trunk in hybrid surgical-endovascular approaches in treatment of extensive thoracic aortic aneurysm.

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Endovascular repair after stent elephant trunk procedure for extensive thoracic aortic aneurysm

Shang Dong Xu 1 Zhan Ming Fan 0 Yu Li 0 Fang Jiong Huang 1 0 Division of Radiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Vascular Diseases, Capital Medical University , Beijing, China 1 Division of Cardiac Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Vascular Diseases, Capital Medical University , Beijing, China Hybrid surgical-endovascular procedure was conducted in a 46-year-old male with extensive thoracic aortic aneurysm. Ascending aorta and arch replacement combined with stent elephant trunk implantation was performed first. An open stent-graft was implanted into the descending aorta. One month later, endovascular repair was conducted. Postoperative CTA showed total coverage of the descending aorta by stent-grafts and the descending aortic aneurysm was totally thrombo-excluded. Stent elephant trunk may be a better alternative to conventional elephant trunk in hybrid surgical-endovascular approaches in treatment of extensive thoracic aortic aneurysm. 2008 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. 1. Introduction Repairing of the extensive thoracic aortic aneurysm by hybrid approaches (proximal elephant trunk procedure followed by endovascular repair of the descending aortic aneurysm) had achieved good results w1x. In recent years, stent elephant trunk emerged as an alternative to conventional elephant trunk w2x. Herein, endovascular repair after stent elephant trunk procedure is reported. 2. Case report A 46-year-old male presented to our hospital with chronic back pain for four months. Extensive thoracic aortic aneurysm was confirmed by magnetic resonance angiography (Fig. 1). The diameter of the ascending aorta, arch and descending aorta was 5.2 cm, 3.4 cm and 7.0 mm, respectively. Hybrid approaches were scheduled. Ascending aorta and arch replacement combined with stent elephant trunk implantation was performed through median sternotomy. An open stent-graft (F 28 mm=100 mm, Cronus, Microport, Shanghai, China) was implanted into the descending aorta through the aortic arch under circulation arrest. The proximal end of the stent-graft was connected with a fourbranched vascular graft (F 28 mm, Intervascular, La Ciotat, France). Postoperative course was uneventful. Computer tomography angiography (CTA) showed a wide opened stent elephant trunk and thrombus formed around the graft. One month later, endovascular repair was conducted under local anesthesia in the catheter lab. Left femoral artery was used as accessing artery. Three stent-grafts (F 28 mm= 170 mm, F 28 mm=120 mm, F 30 mm=170 mm, Grinkin, Beijing, China) were deployed one by one from distal to proximal. The endovascular repair procedure was described in detail in our previous paper w3x. The aorta just above the celiac trunk was used as distal landing zone. The stent elephant trunk served as the proximal landing zone by overlapping with the third stent-graft. Postoperative process was uneventful. Postoperative CTA showed total coverage of the descending aorta by stent-grafts and the descending aortic aneurysm was totally thrombo-excluded (Fig. 2). 3. Discussion Hybrid surgical-endovascular approaches have achieved better results than 2-stage surgical procedures in the treatment of an extensive thoracic aortic aneurysm w4x. Endovascular repair after stent elephant trunk procedure has not been reported in the literature yet. When hybrid approaches are used, the stent elephant trunk may have some advantages over conventional ones. First, the conventional elephant trunk is invisible under fluoroscopy unless some markers (like hemoclips or pacer wires) have been attached to it; while a stent elephant trunk can be seen very clearly under fluoroscopy. Second, since the stent elephant trunk is nearly straight, wide open and stable in the descending aorta, a guide wire can pass through it easily from distal end to proximal end and all the way up to the ascending aorta; while the conventional elephant trunk may be kinking, tortuous or compressed in the descending aorta, especially when the elephant trunk is relatively long ()10 cm). It is not easy to pass a guide wire into its distal end and through its whole length. In such case, a guide wire is needed to be threaded into its proximal end and through its whole length, then all the way down to the descending aorta, abdominal aorta, iliac artery and femoral artery. Finally, its tip is pulled out through arteriotomy in the femoral artery. This will make the whole procedure more complex. Third, a rigid, stable and wide opened stent elephant trunk serves as a better Fig. 2. Computer tomography angiography (CTA) of the patient. (Left) CTA after stent elephant trunk procedure. (Right) CTA after endovascular repair. proximal landing zone than a soft and maybe tortuous conventional elephant trunk. Since the whole length of the descending aorta would be covered by stent-grafts and no intercostal artery reconstruction would be conducted, paralysis was a major concern for this patient before endovascular repair. During the procedure, aortography did not show any patent intercostal artery. So we didnt hesitate to cover the whole length of the descending aorta with stent-grafts. Occlusion of the intercostal arteries may be due to the artherosclerosis of the aneurysm wall. The stent elephant trunk may be a better alternative to conventional elephant trunk in hybrid surgical-endovascular approaches in the treatment of an extensive thoracic aortic aneurysm.


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Shang Dong Xu, Zhan Ming Fan, Yu Li, Fang Jiong Huang. Endovascular repair after stent elephant trunk procedure for extensive thoracic aortic aneurysm, Interactive CardioVascular and Thoracic Surgery, 2008, 1189-1190, DOI: 10.1510/icvts.2008.184051