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Innovative Endovascular Treatment of a Patient with Acutely Painful Thoracoabdominal Aortic Aneurysm with Rapid Expansion with a Novel Quadruple Layer Stent Technique ARTICLE in EXPERIMENTAL AND CLINICAL CARDIOLOGY · SEPTEMBER 2014 Impact Factor: 0.76

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EXPERIMENTAL & CLINICAL CARDIOLOGY

Volume 20, Issue 9, 2014

Title: "Innovative Endovascular Treatment of a Patient with Acutely Painful Thoracoabdominal Aortic Aneurysm with Rapid Expansion with a Novel Quadruple Layer Stent Technique"

Authors: Bruno Leonardo De Freitas Soares, Cezar R. A. Silva, Josue M. Dantas, Joaquim A. Sampaio, Marina R. Pitta and Guilherme Benjamin Brandao Pitta

How to reference: Innovative Endovascular Treatment of a Patient with Acutely Painful Thoracoabdominal Aortic Aneurysm with Rapid Expansion with a Novel Quadruple Layer Stent Technique/Bruno Leonardo De Freitas Soares, Cezar R. A. Silva, Josue M. Dantas, Joaquim A. Sampaio, Marina R. Pitta and Guilherme Benjamin Brandao Pitta/Exp Clin Cardiol Vol 20 Issue9 pages 5294-5296 / 2014

Innovative Endovascular Treatment of a Patient with Acutely Painful Thoracoabdominal ...

Experimental & Clinical Cardiology

Quadruple layer stent in the treatment of expansive painful TAA aneurysm Case Report

Bruno Leonardo de Freitas Soares1,3*, Cézar Ronaldo Alves da Silva2, Josué Medeiros Dantas2, Joaquim Araújo Sampaio2, Marina Regueira Pitta2 and Guilherme Benjamin Brandão Pitta2 1 Department of Visceral, Thoracic, Transplant and Vascular Surgery, Faculty of Medicine, University of Leipzig, Leipzig, Germany 2 Division of Vascular Surgery, Arthur Ramos Memorial Hospital, Maceió, Brazil. 3 Faculty of Medicine, Federal University of São Francisco Valley, Petrolina, Brazil

© 2013 et al.; licensee Cardiology Academic Press. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Exp Clin Cardiol, Volume 20, Issue 9, 2014 - Page 5294

Innovative Endovascular Treatment of a Patient with Acutely Painful Thoracoabdominal ...

Abstract

Open surgical repair of thoracoabdominal aortic

aneurysm (TAAA) is a major procedure with significant perioperative mortality and morbidity in recent series. Furthermore, conventional surgical treatment has a higher mortality rate when associated emergency treatment and in the presence of systemic diseases such as pulmonary

The chosen surgical technique in this scenario was the quadruple layer nitinol stent deployment technique (Braile Biomédica, São José do Rio Preto, Brazil). Right common femoral artery catheterization, with introduction of a 5F pigtail catheter up to the left subclavian artery, through a 5French sheath, which allowed the insertion of an Amplatz super-stiff guidewire (Boston Scientific, USA).

emphysema, diabetes and renal failure, and advanced age. Endovascular

repair

remains

nowadays

a

potential

alternative to emergency open surgical repair for acutely painful expansive thoracoabdominal aneurysms in selected patients, with an uprising number of data describing the results obtained with a range of devices. To our best knowledge, we present the first reported endovascular repair of an acutely painful expansive thoracoabdominal aneurysm patient, successfully treated with the use of a novel quadruple nitinol stent deployment technique. Keywords Thoracoabdominal aneurysm, Endovascular procedures, Stent, Expansive aortic aneurysm

1.

Introduction

The advent and constant evolution of the recent minimally invasive endovascular treatment modalities for aneurysmatic disease has strongly impacted recent medical practice and posed new possibilities for its handling as well as widened the spectrum of patients suitable for these therapeutic options. Open

surgical repair of thoracoabdominal aortic aneurysm (TAAA) is a major procedure with significant perioperative mortality and morbidity in recent series. Furthermore, conventional surgical treatment has a higher mortality rate when associated emergency treatment and in the presence of chronic systemic diseases. Endovascular repair remains nowadays a potential alternative to emergency open surgical repair for acutely painful expansive thoracoabdominal aneurysms in selected patients, with an uprising number of data describing the results obtained with a range of devices. As a continuation of previous basic research publications from our group1-4, we present the first reported endovascular repair of an acutely painful expansive thoracoabdominal aneurysm patient, successfully treated with the use of a novel quadruple nitinol stent deployment technique. 2.

Case report

a

b

Figure 1. Periprocedural data. Preoperative Tomography : a) Coronal view. b) Transversal view

Dissection of the left brachial artery, insertion of a 5-French sheath, followed by catheterization of the abdominal Aorta with a 5-French Cobra catheter (Boston Scientific, USA), which was then exchanged for a pigtail sizing catheter (Boston Scientific, USA) located immediately bellow de offspring of the left subclavian artery. Following angiography confirmed the previous angioCT findings, and a disturbed intrasac arterial flow was registered. The 5-French right inguinal sheath was exchanged for a 18French introducer, with following passage and deployment of a 40x150mm nitinol stent (Braile Biomédica, Brazil), with its proximal extremity laying at the level of the celiac trunk, and the distal end at the level of the offspring of the renal arteries.(figure 2a.) The second stent (40x150mm, Braile Biomédica, Brazil) was deployed with its proximal end below the offspring of the renal arteries and the distal extremity at the medial portion of the right common iliac artery. Implantation of the third stent (40x150mm, Braile Biomédica, Brazil) immediately below the offspring of the renal arteries until the proximal portion of the right common iliac artery, sealing the two previously deployed stents. The fourth stent (34x200mm, Braile Biomédica, Brazil) was then implanted, from below the offspring of the left common subclavian artery until the level of the renal arteries.(Figure 2a, 2b) Thoracic and abdominal aortic post ballooning with a Gore Tri-lobe balloon (W.L. Gore & Associates, USA) in proximal, medial and distal stent regions. For the external right iliac artery stenosis, we performed balloon angioplasty, using a 8x80mm PTA Balloon (Cook Medical, USA).

77 years old female patient, heavy smoker, obese, with descompensated congestive heart failure and chronic pulmonary obstructive disease (COPD), presenting with acutely painful abdomen, dyspnea and arterial hypertension on admission. Computed angiotomography (angioCT) During intraoperative angiographic control, after the evidenced a thoracoabdominal aortic aneurysm with rapid implantation of the second stent, evidenced shift to central expansion in its abdominal segment, measuring 5.6cm at the laminar arterial flow, with assured patency to the visceral, level of the pulmonary arteries, with important tortuosity renal, and right iliac arteries. Angiographic control after the below this level and reducing its transverse diameter to deployment of the third stent and the fourth stent, evidenced 3.2cm, until the offspring of the renal arteries. At this level, a laminar central flow into the right iliac common and external neckless expansive 7.6cm abdominal aortic aneurysm was arteries, as well as patent central laminar flow to the celiac found, with thrombus diffusely distributed within the trunk, superior and inferior mesenteric arteries and to the aneurysmatic sac. An important diffuse arterial calcification renal arteries, respectively.(Figure 2b) with chronic compensated occlusion of the left common iliac Exp Clin Cardiol, Volume 20, Issue 9, 2014 - Page 5295 artery, and reduced diameter of the common and external right iliac arteries was present. (Figure 1)

Innovative Endovascular Treatment of a Patient with Acutely Painful Thoracoabdominal ...

The patient presented with a post-implantation syndrome(PIS) on the third postoperative day, with thoracic pain, acute anemia, dyspnea, with reduced prothrombin time activity(64%) and platelet number (160.000), although remaining hemodynamically stable, with good diuresis rate and without fever or vasoactive drugs. As antiplatelet drugs were withdrawn and palliative symptomatic therapy was implemented, after what the patient presented clinical improvement and discharge occurred with no further complications. The intervention led to a complete exclusion of the aneurysm sac. Control angioCT was performed on the 10th postoperative day, with patent visceral, renal and iliac arteries, intraluminal laminar central flow within the four stents and a small contrast endoleak in the distal end of the first stent with thrombosed aneurysmatic sac. Follow up performed on the 10th, 30th and 90th postoperative day, revealed completely thrombosed aneurysmatic sac with no endoleak. (Figure 2b.)

a

4. References 1. Aquino M. Gradiente de pressão na correção endovascular do aneurisma de aorta em porcos com stents tripla camada. [Tese de mestrado]. Porto Alegre: UFRGS, 2012. 2. Pitta GBB, Silva CRA, Medeiros JD, Santos AD. Stents em tripla camada no tratamento endovascular do aneurisma de aorta abdominal em expansão. Rev Bras Cir Cardiovasc 2012;27(1):123-4. 3. Silva Júnior SL. Modelo experimental estável de aneurisma sacular em artéria carótida de suínos utilizando veia jugular interna. Rev. Col. Bras. Cir. 2013; 40(2): 130-136. 4. Oliveira JR. Alterações do padrão do fluxo sanguíneo após tratamento endovascular do aneurisma sacular da aorta com triplo stent: modelo em suínos. [Tese de mestrado]. Porto Alegre: UFRGS, 2012.

b

Figure 2. Periprocedural data: a) Stent deployment b) 90-days postoperative follow up control AngioCT

Three-month follow-up showed shrinkage of the aneurysm on CT angiography with patent stent and visceral arteries and no complications, suggesting successful treatment. 3. Conclusion The endovascular approach with this quadruple stent multilayer technique resulted to be technically feasible and beneficial for this patient. The use of this new stent device may be a promising alternative to the other techniques, leading to exclusion of the aneurysm while not occluding the visceral arteries orifices. The endovascular repair for thoracoabdominal aortic aneurysmatic diseases are still emerging and they are not statistically significant in terms of medium-term mortality rates, as a longer follow-up period of patients who underwent these new procedures is needed to prove their success. Especially in patients with an occlusion of the contralateral Iliac artery, one can avoid more invasive Exp Clin Cardiol, Volume 20, Issue 9, 2014 - Page 5296 treatment strategies, although long-term data on branch vessel patency are necessary.