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Endovascular stent grafting for contained rupture of the descending thoracic aorta

Endovascular stent grafting for contained rupture of the descending thoracic aorta Abstract We report three cases of contained rupture of the descending thoracic aorta managed by endovascular stent grafting and discuss the possibility of managing this life-threatening complication in emergency, by endoluminal devices. Further experience is needed to specify the indications for aortic stenting in descendant thoracic aortic ruptures. Aortic rupture, Endoprosthesis, Aortic salmonellosis, Aortic hematoma, Aorto-esophageal fistula 1 Introduction The use of endoluminal devices in the treatment of aortic diseases is progressing [1,2]. We describe three cases of contained aortic ruptures treated by endovascular stent grafting. These cases represent our initial experience and are described in chronological order. At the time, we had to order the prostheses. We now have a readily available supply of 10-cm prostheses for emergency use, in the following diameters: 24, 28, 32,38 and 42 mm. 2 Case reports 2.1 Case 1 A 77-year-old man with a history of smoking and prostate adenoma presented in February 2000 with acute dorsal pain with lumbar irradiation, dyspnea and left limb paresthesia. Trans-esophageal echography revealed a post-subclavian aortic rupture with a small left pleural effusion confirmed by contrast computer tomography (CT) scan. The patient was managed medically with anti-hypertensive treatment and drainage of a 1.1-l left hemothorax. One week later, the left hemothorax reappeared. Angiography showed three aortic fissure lesions at different levels of the thoracic aorta. CT scan confirmed the rupture (Fig. 1) . A 30-mm diameter, 101-mm long Talent type endoprosthesis (World Medical Corp., Sunrise, FL) was deployed 1 cm from the origin of the left subclavian artery. After the procedure, thoracic drainage eliminated a 1.8-l left hemothorax. The hemothorax did not reappear and the control CT scan showed no leak. The patient's recovery was uneventful and he is doing well 34 months after the procedure. Contrast thoraco-abdominal control CT scans done every 6 months have shown no leak, stent migration or other complication. Fig. 1 Open in new tabDownload slide Case 1. The aortic rupture is confirmed by the CT scan (1.1); the angiography showed three levels of rupture (1.2), covered by the stent graft (1.3). Fig. 1 Open in new tabDownload slide Case 1. The aortic rupture is confirmed by the CT scan (1.1); the angiography showed three levels of rupture (1.2), covered by the stent graft (1.3). 2.2 Case 2 A 78-year-old woman with a history of arterial hypertension, appendectomy, salmonellosis and polyarthritis was examined in January 2001 for acute left basithoracic pain, dyspnea and fever. Thoracic radiography showed a left pleural effusion. A contrast thoracic CT scan revealed an aortic hematoma with a contrast leak at the level of the ninth dorsal (D9) vertebra and the angiography also showed the level of the rupture (Fig. 2) . The zone was covered using two 31-mm long Talent type endoprostheses. Control arteriography during the procedure showed a persistent leak between the two stents, so a third one was deployed. A control contrast thoracic CT scan done 3 days later revealed no contrast leak and a regression of the aortic hematoma. At postoperative day 8, the patient had a high fever with shivering and a positive hemoculture for Salmonella enteridis. Antibiotics were given and the fever and inflammatory markers regressed; treatment was stopped 18 months ago and the patient is doing well. Due to the risk of graft infection, this patient requires close supervision. Fig. 2 Open in new tabDownload slide Case 2. CT scan (2.1) and angiography (2.2) showed the aortic rupture which was covered by the stent graft (2.3). Fig. 2 Open in new tabDownload slide Case 2. CT scan (2.1) and angiography (2.2) showed the aortic rupture which was covered by the stent graft (2.3). 2.3 Case 3 A 59-year-old woman with a medical history of arterial hypertension, morbid obesity and smoking presented in December 2001 with a left pleural effusion after 3 weeks of persistent undiagnosed fever, asthenia, and progressive dysphagia. A contrast CT scan revealed a spontaneous aortic rupture with a peri-aortic hematoma compressing the esophagus and the left atrium (Fig. 3) . Fig. 3 Open in new tabDownload slide Case 3. CT scan (3.1) showed an aortic rupture with a peri-aortic hematoma and the angiography (3.2) showed the contrast leak in the peri-aortic space; after stent deployment, the contrast leak disappeared (3.3). Fig. 3 Open in new tabDownload slide Case 3. CT scan (3.1) showed an aortic rupture with a peri-aortic hematoma and the angiography (3.2) showed the contrast leak in the peri-aortic space; after stent deployment, the contrast leak disappeared (3.3). A 25-mm diameter Talent type endoprosthesis was deployed to cover and exclude the aortic rupture area. There were no procedural complications. On the 7th postoperative day, the patient had a moderate hematemesis. An upper fibroscopy revealed an aorto-esophageal fistula 30 cm from the dental arcades and an esophageal ulcer covered with clots. Thoracic CT scan excluded migration or stent kinking. The aorto-esophageal fistula was managed surgically by esophageal resection with bilateral exclusion by right thoracotomy, cervical esophagostomy and gastrostomy. The patient recovered well in the early postoperative period but developed sepsis and died 2 months later. 3 Discussion These cases show that acute contained rupture of the thoracic aorta can be treated by endovascular stenting. As this technique is new, each team's experience is needed in order to determine the right indication. In our experience, as described in another paper [3], the compression of the esophagus at the time of diagnosis is a contraindication for an endoluminal procedure. In such cases, conventional treatment is preferable as it treats not only the rupture, but also relieves the esophageal compression caused by the periaortic hematoma and the intra-aneurysmal thrombosis, which are, in our opinion, responsible for the further aorto-esophageal fistula. Moreover, the fragile ischemic esophageal area may be subject to mechanical aggression caused by the retraction of the aneurysm or the hematoma after stenting. In the second case, the rupture is likely to have been caused by infection (salmonella). The risk of sepsis is identical with both surgical and endoluminal techniques in our opinion. We show that endoluminal treatment is possible in such cases, associated with antibiotherapy which should be initiated immediately before the endovascular treatment. With experience, the endoluminal technique is being used for more and more patients. In our initial experience we limited the use of this technique to fragile patients. We now propose this kind of treatment to a wider population, i.e. to patients who could undergo a thoracotomy. As always with new techniques, the initial enthusiasm is tempered by complications which allow to define the right indications. Endoluminal treatment of contained aortic rupture is not the standard treatment. Even if this technique may be successful in some cases, more data are needed to determine the safety of this approach. In the case of aortic contained rupture, esophageal compression by the hematoma is a contraindication for endoluminal treatment. The authors thank Nancy Richardson-Peuteuil for her editorial assistance. References [1] Brittenden J. , McBride K. , McInnes G. , Gillespie I.N. , Bradbury A.W. . The use of endovascular stents in the treatment of penetrating ulcers of the thoracic aorta , J Vasc Surg , 1999 , vol. 30 5 (pg. 946 - 949 ) Google Scholar Crossref Search ADS PubMed WorldCat [2] Murgo S. , Dussaussois L. , Golzarian J. , Cavenaile J.C. , Abada H.T. , Ferreira J. , Struyven J. . Penetrating atherosclerotic ulcer of the descending thoracic aorta: treatment by endovascular stent-graft , Cardiovasc Intervent Radiol , 1998 , vol. 21 6 (pg. 454 - 458 ) Google Scholar Crossref Search ADS PubMed WorldCat [3] Chocron S. , Stoica L. , Koch S. , Bonneville J.-F. , Heyd B. , Etievent J.-P. . Is endovascular stent grafting for descending thoracic aortis disease recommendable in patients with dysphagia? , J Thorac Cardiovasc Surg , 2002 , vol. 124 (pg. 1239 - 1241 ) Google Scholar Crossref Search ADS PubMed WorldCat © 2003 Elsevier Science B.V. 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Endovascular stent grafting for contained rupture of the descending thoracic aorta

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Publisher
Oxford University Press
Copyright
© 2003 Elsevier Science B.V.
Subject
Case report
ISSN
1010-7940
eISSN
1873-734X
DOI
10.1016/S1010-7940(03)00112-X
Publisher site
See Article on Publisher Site

Abstract

Abstract We report three cases of contained rupture of the descending thoracic aorta managed by endovascular stent grafting and discuss the possibility of managing this life-threatening complication in emergency, by endoluminal devices. Further experience is needed to specify the indications for aortic stenting in descendant thoracic aortic ruptures. Aortic rupture, Endoprosthesis, Aortic salmonellosis, Aortic hematoma, Aorto-esophageal fistula 1 Introduction The use of endoluminal devices in the treatment of aortic diseases is progressing [1,2]. We describe three cases of contained aortic ruptures treated by endovascular stent grafting. These cases represent our initial experience and are described in chronological order. At the time, we had to order the prostheses. We now have a readily available supply of 10-cm prostheses for emergency use, in the following diameters: 24, 28, 32,38 and 42 mm. 2 Case reports 2.1 Case 1 A 77-year-old man with a history of smoking and prostate adenoma presented in February 2000 with acute dorsal pain with lumbar irradiation, dyspnea and left limb paresthesia. Trans-esophageal echography revealed a post-subclavian aortic rupture with a small left pleural effusion confirmed by contrast computer tomography (CT) scan. The patient was managed medically with anti-hypertensive treatment and drainage of a 1.1-l left hemothorax. One week later, the left hemothorax reappeared. Angiography showed three aortic fissure lesions at different levels of the thoracic aorta. CT scan confirmed the rupture (Fig. 1) . A 30-mm diameter, 101-mm long Talent type endoprosthesis (World Medical Corp., Sunrise, FL) was deployed 1 cm from the origin of the left subclavian artery. After the procedure, thoracic drainage eliminated a 1.8-l left hemothorax. The hemothorax did not reappear and the control CT scan showed no leak. The patient's recovery was uneventful and he is doing well 34 months after the procedure. Contrast thoraco-abdominal control CT scans done every 6 months have shown no leak, stent migration or other complication. Fig. 1 Open in new tabDownload slide Case 1. The aortic rupture is confirmed by the CT scan (1.1); the angiography showed three levels of rupture (1.2), covered by the stent graft (1.3). Fig. 1 Open in new tabDownload slide Case 1. The aortic rupture is confirmed by the CT scan (1.1); the angiography showed three levels of rupture (1.2), covered by the stent graft (1.3). 2.2 Case 2 A 78-year-old woman with a history of arterial hypertension, appendectomy, salmonellosis and polyarthritis was examined in January 2001 for acute left basithoracic pain, dyspnea and fever. Thoracic radiography showed a left pleural effusion. A contrast thoracic CT scan revealed an aortic hematoma with a contrast leak at the level of the ninth dorsal (D9) vertebra and the angiography also showed the level of the rupture (Fig. 2) . The zone was covered using two 31-mm long Talent type endoprostheses. Control arteriography during the procedure showed a persistent leak between the two stents, so a third one was deployed. A control contrast thoracic CT scan done 3 days later revealed no contrast leak and a regression of the aortic hematoma. At postoperative day 8, the patient had a high fever with shivering and a positive hemoculture for Salmonella enteridis. Antibiotics were given and the fever and inflammatory markers regressed; treatment was stopped 18 months ago and the patient is doing well. Due to the risk of graft infection, this patient requires close supervision. Fig. 2 Open in new tabDownload slide Case 2. CT scan (2.1) and angiography (2.2) showed the aortic rupture which was covered by the stent graft (2.3). Fig. 2 Open in new tabDownload slide Case 2. CT scan (2.1) and angiography (2.2) showed the aortic rupture which was covered by the stent graft (2.3). 2.3 Case 3 A 59-year-old woman with a medical history of arterial hypertension, morbid obesity and smoking presented in December 2001 with a left pleural effusion after 3 weeks of persistent undiagnosed fever, asthenia, and progressive dysphagia. A contrast CT scan revealed a spontaneous aortic rupture with a peri-aortic hematoma compressing the esophagus and the left atrium (Fig. 3) . Fig. 3 Open in new tabDownload slide Case 3. CT scan (3.1) showed an aortic rupture with a peri-aortic hematoma and the angiography (3.2) showed the contrast leak in the peri-aortic space; after stent deployment, the contrast leak disappeared (3.3). Fig. 3 Open in new tabDownload slide Case 3. CT scan (3.1) showed an aortic rupture with a peri-aortic hematoma and the angiography (3.2) showed the contrast leak in the peri-aortic space; after stent deployment, the contrast leak disappeared (3.3). A 25-mm diameter Talent type endoprosthesis was deployed to cover and exclude the aortic rupture area. There were no procedural complications. On the 7th postoperative day, the patient had a moderate hematemesis. An upper fibroscopy revealed an aorto-esophageal fistula 30 cm from the dental arcades and an esophageal ulcer covered with clots. Thoracic CT scan excluded migration or stent kinking. The aorto-esophageal fistula was managed surgically by esophageal resection with bilateral exclusion by right thoracotomy, cervical esophagostomy and gastrostomy. The patient recovered well in the early postoperative period but developed sepsis and died 2 months later. 3 Discussion These cases show that acute contained rupture of the thoracic aorta can be treated by endovascular stenting. As this technique is new, each team's experience is needed in order to determine the right indication. In our experience, as described in another paper [3], the compression of the esophagus at the time of diagnosis is a contraindication for an endoluminal procedure. In such cases, conventional treatment is preferable as it treats not only the rupture, but also relieves the esophageal compression caused by the periaortic hematoma and the intra-aneurysmal thrombosis, which are, in our opinion, responsible for the further aorto-esophageal fistula. Moreover, the fragile ischemic esophageal area may be subject to mechanical aggression caused by the retraction of the aneurysm or the hematoma after stenting. In the second case, the rupture is likely to have been caused by infection (salmonella). The risk of sepsis is identical with both surgical and endoluminal techniques in our opinion. We show that endoluminal treatment is possible in such cases, associated with antibiotherapy which should be initiated immediately before the endovascular treatment. With experience, the endoluminal technique is being used for more and more patients. In our initial experience we limited the use of this technique to fragile patients. We now propose this kind of treatment to a wider population, i.e. to patients who could undergo a thoracotomy. As always with new techniques, the initial enthusiasm is tempered by complications which allow to define the right indications. Endoluminal treatment of contained aortic rupture is not the standard treatment. Even if this technique may be successful in some cases, more data are needed to determine the safety of this approach. In the case of aortic contained rupture, esophageal compression by the hematoma is a contraindication for endoluminal treatment. The authors thank Nancy Richardson-Peuteuil for her editorial assistance. References [1] Brittenden J. , McBride K. , McInnes G. , Gillespie I.N. , Bradbury A.W. . The use of endovascular stents in the treatment of penetrating ulcers of the thoracic aorta , J Vasc Surg , 1999 , vol. 30 5 (pg. 946 - 949 ) Google Scholar Crossref Search ADS PubMed WorldCat [2] Murgo S. , Dussaussois L. , Golzarian J. , Cavenaile J.C. , Abada H.T. , Ferreira J. , Struyven J. . Penetrating atherosclerotic ulcer of the descending thoracic aorta: treatment by endovascular stent-graft , Cardiovasc Intervent Radiol , 1998 , vol. 21 6 (pg. 454 - 458 ) Google Scholar Crossref Search ADS PubMed WorldCat [3] Chocron S. , Stoica L. , Koch S. , Bonneville J.-F. , Heyd B. , Etievent J.-P. . Is endovascular stent grafting for descending thoracic aortis disease recommendable in patients with dysphagia? , J Thorac Cardiovasc Surg , 2002 , vol. 124 (pg. 1239 - 1241 ) Google Scholar Crossref Search ADS PubMed WorldCat © 2003 Elsevier Science B.V. Elsevier Science B.V.

Journal

European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Jun 1, 2003

Keywords: Aortic rupture Endoprosthesis Aortic salmonellosis Aortic hematoma Aorto-esophageal fistula

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