Thoracic endovascular repair of descending thoracic aorta aneurysm using thoracic stent graft in a challenging complex patient: An innovative access technique during an emergency using a mini-thoracotomy approach

Introduction

Thoracic endovascular aortic repair (TEVAR) is preferred over open surgery since the latter is associated with higher morbidity, mortality, and postoperative stay. ¹ Patients who undergo TEVAR have low reintervention and aneurysm-associated mortality rates over a 5-year period. ²

The anatomical characteristics of the patient may be a constraint in the TEVAR procedure. In the standard TEVAR procedure, the device is delivered through the femoral artery. However, patients with severely tortuous access vessels, who require a larger profile delivery system, and women with small-diameter access arteries are at an elevated risk of access-related adverse events. ³ The increase in risk of complications, such as endoleak, is associated with a short proximal neck, curvature, or significant angulation. This adverse event has also been observed in endovascular abdominal aortic repair.^4–6

The standard TEVAR procedure involves delivering the stent device into the femoral artery, common iliac artery, or abdominal aorta. We present a case of a 52-year-old man who arrived at the emergency department with severe chest pain. Thoracic computed tomography angiography (CTA) revealed a descending thoracic aortic aneurysm. His past medical history included multiple abdominal surgeries and infrarenal aortic ligation with an axillobifemoral bypass. An emergency TEVAR was planned. However, owing to the history of infrarenal aortic ligation, stent device vascular access through the femoral and iliac arteries, and an open abdominal aorta, was impossible. Therefore, we developed a novel technique for gaining vascular access to a descending thoracic aortic aneurysm via a mini-thoracotomy approach, in which the vascular access stent device was successfully delivered into the descending thoracic aorta. ¹

This report demonstrates an innovative technique during an emergency to gain vascular access to a descending thoracic aortic aneurysm through a left posterolateral mini-thoracotomy incision, avoiding the need for open thoracotomy repair.

Case presentation

A 56-year-old male patient with hypertension presented to the emergency department with a 3-day history of chest pain. The pain was intermittent and sudden in nature, aggravated by walking, and unrelieved by rest. The patient denied any history of sweating, weakness, or shortness of breath. Moreover, he denied any history of abdominal or other lower limb pain. His past surgical history was significant, as he underwent infrarenal aortic ligation and right axillobifemoral bypass at a different hospital in 2011 for a huge dilated infrarenal abdominal aortic aneurysm following endovascular repair of a proximal leak with contained rupture and an infected aortic graft. Subsequently, complications developed, including multiple duodenal perforations, which were managed with open laparotomy and primary repair of perforations by the hepatobiliary surgery team. Later, he developed an enterocutaneous fistula and underwent ileostomy exclusion due to pouring of the intestinal contents into the left groin. Owing to this ileostomy and the intestinal materials, the patient developed erosion of the left iliac arteries, which was managed by embolization. In 2014, he presented with rectal bleeding, and left-sided colonoscopy revealed a right iliac artery enteric fistula in the sigmoid colon, which was managed by diversion ileostomy, local drainage, and antibiotics. Given the patient’s history, a comprehensive investigation for any underlying connective tissue disease was conducted; however, this yielded no positive clinical or serological results. Moreover, the patient underwent extensive infectious disease evaluation with multiple blood cultures looking for infected mycotic aortic aneurysm; however, no infectious etiology was discovered.

Upon general physical examination, the patient reported mild-to-moderate pain. He was vitally stable and afebrile. Chest and cardiac examination results were normal. Both lower limbs were warm with palpable regular pulses and normal capillary refill.

Laboratory examination revealed the following findings: hemoglobin, 12.3 g/dL; leukocyte count, 6.79 × 109/L, and platelet count, 277 × 109/L. Troponin T, cardiac enzyme levels, liver and renal function indices, and coagulation profiles were all within normal ranges. Electrocardiography revealed no abnormalities.

A thoracic CTA three-dimensional manufactured patient-specific model of the aorta revealed saccular aneurysmal dilatation at the junctional region of the aortic arch and descending aorta (zone 2) measuring 4.4 × 4 cm abutting the left main pulmonary artery and associated with eccentric thrombus as well as with atherosclerotic plaques (Supplementary Figure S1).

The patient had a very difficult anatomy with an inadequate landing zone that included the origin of the left common carotid artery, thus promoting us to perform the surgery in two stages. The proximal landing zone was 15 mm from the origin of the left common carotid artery.

The first-stage surgery was partial arch debranching with carotid–carotid and left carotid–subclavian bypass using a ringed 8 mm × 70 cm PTFE vascular graft with a straight configuration (Supplementary Figure S2). During the same hospital stay, the patient was brought to the vascular hybrid operating room for second-stage TEVAR. However, stent device vascular access to the femoral and iliac arteries, as well as an open abdominal aorta, was impossible owing to the history of infrarenal aortic ligation and right axillobifemoral bypass surgery (Figure 1(a) and (b)). Therefore, we developed a technique to gain vascular access to a descending thoracic aortic aneurysm via a left posterolateral mini-thoracotomy approach over the eighth intercostal space. A double-lumen endotracheal tube was inserted; the pleura was opened, and the inferior pulmonary ligament was dissected and released. The descending aorta was identified, and proximal and distal control was achieved when vascular control was required. Descending aorta arteriotomy was performed using a purse-string suture, and a vascular access sheath was placed (Figure 2). Subsequently, a Medtronic Valiant Navion 43 × 103 mm FreeFlo stent graft (Medtronic Inc, Santa Rosa, CA, USA) was used, and the entire aneurysm was excluded. Aortography revealed a good apposition of the thoracic stent graft and complete aneurysmal exclusion. Intraoperative transfusion was not required. Thoracic CTA performed before discharge revealed complete aneurysmal exclusion and no endoleaks (Figure 3). The patient recovered well and was discharged 2 days postoperatively. Follow-up CTA at 6 months postoperatively and annually thereafter revealed no aneurysm formation or aortic restenosis. Written informed consent was obtained from the patient for the publication of this case report and accompanying images.OPEN IN VIEWER

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Figure 2.

Left posterolateral mini-thoracotomy incision over the eighth intercostal space and the vascular access sheath placed at the descending aorta (arrowhead).

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Figure 3.

Thoracic CTA shows successful sealing with complete aneurysmal exclusion and no endoleak.

Discussion

In our case, TEVAR was performed under general anesthesia. In a study by Naughton et al., ⁷ traditional femoral arterial open exposure was used in 32 patients (42%), complete percutaneous access using the suture-mediated closure “preclose” technique in 38 patients (50%), and open iliac artery conduit in 6 patients (8%). There are limited reports on the direct transaortic approach. Two successful cases of direct transaortic TEVAR were reported in 2016; however, the stent grafts were delivered from the ascending aorta. ⁸ Another case report in 2014 published about the successful implantation of a combined transaortic transcatheter aortic valve replacement (TAVR) and a thoracic endograft. Therein, a concomitant TEVAR was performed through the RF3 introducer sheath, which was used to introduce the TAVR. ⁹

In our case, the patient had a history of infrarenal aortic ligation, and stent device vascular access through the femoral and iliac arteries, as well as an open abdominal aorta, was impossible. Vascular access detection in our challenging complex patient was impossible because of several previous vascular surgeries. Therefore, we developed a novel technique using a left posterolateral mini-thoracotomy approach to gain vascular access and perform TEVAR, avoiding the need for open thoracotomy repair. Cambria et al. ¹⁰ presented a multicenter study of descending thoracic aortic emergencies treated with TEVAR compared with open surgical repair. TEVAR reduced the 30-day mortality by half. A 30-day mortality after TEVAR of 19%, compared with 33% in patients treated with open repair, was estimated in a meta-analysis of ruptured degenerative aneurysm repair techniques. ¹¹ TEVAR is recommended for descending thoracic aortic aneurysms over open repair by The Society for Vascular Surgery Clinical Practice Guidelines. ¹² Open repair of the descending thoracic aorta is a physiologically stressful operation with high adverse event and mortality rates. ¹² In the descending thoracic aorta, TEVAR has largely replaced the traditional open repair procedures. Endovascular repair for less common diseases of the descending thoracic aorta ¹² is recommended in the aforementioned guidelines.

Endovascular intervention involves several constraints, such as access restriction in our case. Additionally, surgeons experience several challenges such as the risk of stroke and spinal ischemia, the requirement for long-term surveillance, the requirement for 2-cm proximal and distal landing zones to accomplish fixation and seal, the absence of disease-specific endograft designs providing flexible delivery with durable seal, and attachment.

TEVAR has become the gold standard treatment for acute aortic catastrophe. TEVAR has a higher rate of early technical success than open surgery and has become the treatment of choice for patients with thoracic aortic aneurysms. Long-term surveillance is crucial, considering that late complications are frequent and can have significant serious consequences if not reintervened appropriately.

Conclusion

This case highlights an unusual complex case of a descending thoracic aortic aneurysm with previous history of multiple vascular surgeries, making endovascular intervention impossible due to various access restrictions. When planning TEVAR, it is crucial to carefully consider the patient’s anatomy and any previous vascular procedures to maintain vigilance regarding lower limb and kidney compromise, as in our case.

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