Fenestrated Stent Graft for Contained Ruptured Type IV Thoraco-Abdominal Aortic Aneurysm
Article Outline
Abstract
We present a successful emergency repair of a contained rupture of a type IV thoraco-abdominal aortic aneurysm using a fenestrated stent graft. This case describes a rupture of a thoraco-abdominal aneurysm whilst the patient awaited manufacture of his custom-fenestrated endograft. Following rupture, he was transferred to our unit from his base hospital, the graft was sourced and implanted 24
h post rupture.
Fenestrated stent grafting of ruptured aneurysms is feasible. Wide application of this technique is likely to remain limited due to stent-graft availability and preoperative stability.
Keywords: Fenestrated, Aneurysm, AAA, EVAR
Type IV thoraco-abdominal aortic aneurysms (TAAAs), according to the Crawford's classification, originate at the level of the diaphragm and terminate at the aortic bifurcation. They represent a minority of aortic aneurysms.
Management of type IV TAAAs is complicated by the necessity to preserve the visceral aortic branches. Currently, the only treatment modality for rupture of type IV aneurysms is open surgery. The reported 30-day mortality rates of patients undergoing acute open repair is 13–55%.1 However, many patients are simply too unfit to be considered for surgery.
Endovascular abdominal aortic aneurysm repair (EVAR) is associated with low perioperative morbidity and mortality in patients with suitable aneurysm morphology. There is evolving evidence for its utility in the management of infrarenal ruptured aneurysms.
Case report
A 64-year-old man with a known 8-cm type IV TAAA presented to his local hospital with an evident rupture. A subsequent unenhanced computed tomography (CT) scan demonstrated a contained retroperitoneal haematoma (Fig. 1). His co-morbidities including chronic obstructive pulmonary disease (COPD), ischaemic heart disease (IHD) (recent myocardial infarction (MI)) and renal failure had prohibited an elective open repair. His single left kidney exhibited chronic impairment, with an estimated glomerular filtration rate of 32mlmin−1 (stage 3 chronic renal failure (CRF)).
Figure 1
Axial unenhanced CT image showing the ruptured AAA.
Weeks prior to this presentation, he had been assessed at our centre for fenestrated stent grafting of the aneurysm (Fig. 2). He presented with aneurysm rupture whilst awaiting elective repair.
Figure 2
Sagittal MIP image demonstrating the relationship of the visceral vessels to the Type IV TAAA.
Following diagnosis of rupture, he was started on intravenous β-blockade and nitrate and transferred to our centre. His custom-made fenestrated stent graft was located and delivery expedited. He remained physiologically stable with a haemoglobin of 10.4gdl−1. Surgery commenced 24h after presentation.
A bilateral common femoral artery cut-down was performed. The three fenestration bifurcated endograft (Zenith, Cook, Brisbane, Australia) was positioned and orientated via the left common femoral artery. The graft was partially deployed to allow cannulation of each visceral vessel with C2 Cobra catheters (Cook Medical Inc., USA) via the graft (Fig. 3). The coeliac, superior mesenteric and left renal arteries were stented with 9, 8 and 6mm Atrium (Atrium Medical Corp., USA) balloon, expandable, covered stents; each graft was flared proximally. The procedure was completed in the standard way following deployment of the bifurcated stent-graft aortic body and the iliac limb extensions. Completion angiography confirmed no endoleak.
Figure 3
Angiographic image showing the coeliac, SMA and single left renal arteries cannulated.
The procedural time was 170min. Four litres of crystalloid and 2 units of blood were administered intra-operatively. A further 4 units of blood, 2 pools of platelets and 3 pools of fresh frozen plasma were infused in intensive care unit (ICU) in the following 24h, until discharge to the general ward.
A completion duplex scan demonstrated a type III endoleak at the attachment site of the superior mesenteric artery (SMA) stent. This was resolved with the insertion of an additional SMA-covered stent. Following plain radiograph (Fig. 4), the patient was discharged 8 days after presentation. At 6-week follow-up, he was well. A CT scan confirmed aneurysm exclusion without endoleak.
Figure 4
Abdominal radiograph showing the fenestrated endograft.
Discussion
This is the first reported successful branched fenestrated stent graft of a ruptured type IV TAAA. Cases of endovascular management of ruptured complex aneurysms have been reported. One case excluded a mycotic TAAA with deliberate occlusion of the coeliac axis, without attempting to preserve its origin.2 Another unit overcame the challenge of a short, conical infrarenal neck by deploying a composite thoracic and infrarenal stent graft with the uncovered portion of the tube graft placed at the renal orifice.3 This case was complicated by a persistent type 1 endoleak.
On-site pre-procedural customised fenestration has also been reported. Low-temperature electrocautery is used to create unilateral renal fenestrations or a scallop for the SMA origin. These hand-made fenestrations are then marked with gold beads for localisation at fluoroscopy.4
The obvious limitation to fenestrated endografting for AAA rupture is the delay between custom-stent-graft order and delivery. Current lag time between order and delivery is approximately 6 weeks. The anatomical variability of the visceral branch orifices and aneurysm neck morphology appears to preclude ‘off-the-shelf’ fenestrated graft compatibility. This may be a valuable area of future research, designing a set of grafts available for use in the acute setting.
Conflict of Interest
The authors have no conflict of interest to declare.
References
- . Management of thoracoabdominal aneurysm type IV. Eur J Vasc Endovasc Surg. 2005;29:116–123
- . Treatment of a ruptured thoracoabdominal aneurysm with a stent-graft covering the celiac axis. J Endovasc Ther. 2006;13(6):770–774
- . Successful endovascular repair of a ruptured abdominal aortic aneurysm in a patient with unfavorable anatomy. J Vasc Surg. 2006;43:831–833
- . Clinical experience with a customized fenestrated endograft for juxtarenal abdominal aortic aneurysm repair. J Vasc Interv Radiol. 2006;17:1935–1942
PII: S1533-3167(09)00015-6
doi:10.1016/j.ejvsextra.2009.04.002
© 2009 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Fenestrated Stent Graft for Contained Ruptured Type IV Thoraco-Abdominal Aortic Aneurysm , 15 June 2009
