Simultaneous Endovascular Exclusion of Thoracic Aortic Aneurysm with Open Abdominal Aortic Aneurysm Repair

SHORT REPORT

Simultaneous Endovascular Exclusion of Thoracic AorticAneurysm with Open Abdominal Aortic Aneurysm Repair

J. Szmidt,1* O. Rowinski,2 Z. Gałazka,1 T. Jakimowicz,1 S. Nazarewski,1

T. Grochowiecki1 and R. Pacho2

Departments of 1General, Vascular and Transplant Surgery, and 2Radiology, Medical University of Warsaw,Warsaw, Poland

Background. The treatment of aneurysms at multiple sites within the aorta is problematic.Methods. Between March 2002 and June 2003 in the Department of General, Vascular and Transplant Surgery, MedicalUniversity of Warsaw six patients with coexisting abdominal and descending thoracic aortic aneurysms underwentsimultaneous open abdominal aortic aneurysm (AAA) repair and endoluminal thoracic aortic aneurysm (TAA) repair. Theindication for a combined procedure was a diagnosed descending TAA and AAA with no significant risk factors for openaortic surgery or technical contraindications for endovascular treatment of TAA.Results. One patient died in the peri-operative period while the other five patients all recovered well after surgery and weredischarged with both aneurysms excluded.Conclusion. Endovascular treatment of TAA combined with a simultaneous open AAA repair is an efficient and relativelysafe treatment modality in patients with TAA and AAA disqualified from endovascular repair. The fact that thoracotomy isnot a necessity significantly lowers the complication rate in these patients.

Key Words: Multilevel aortic aneurysm; Endovascular thoracic aortic aneurysm treatment; Open abdominal aorticaneurysm surgery.

Introduction

Multilevel aortic aneurysms poses a serious problemfor vascular surgeons in the terms of choice of anadequate surgical method of treatment. Open surgeryis still associated with significant morbidity andmortality especially in patients with thoracic aorticaneurysms (TAA).1–3 Ten to 29% of patients with TAAhave coexisting abdominal aortic aneurysms (AAA).2,4

Historically, multilevel aortic surgery was performedin these patients simultaneously or subsequently.5 Analternative to open surgery could be stentgraft place-ment for TAA and AAA.4 AAA morphology is notalways suitable for endovascular repair (short orconical neck, severe angulations of the neck or iliactortuosity). Additionally, in some patients a goodresult of open aneurysm repair can be predicted. Insuch cases simultaneous stentgraft placement for TAAcombined with open repair for AAA may be a viable

method of treatment. It allows for a lower compli-cation risk, than for a procedure associated with openthoracotomy and high aortic cross-clamping andexcludes both aneurysms from circulation.

Patients and Methods

Between March 2002 and June 2003 in the Departmentof General, Vascular and Transplant Surgery, MedicalUniversity of Warsaw six patients with coexistingAAA and TAA underwent simultaneous openabdominal aneurysm repair and stentgraft placementthrough the implanted gelatin-coated Dacron abdomi-nal vascular prosthesis side limb. This group ofpatients consisted of two females and four maleswith a mean age of 70 years, four of whomwere heavysmokers. Four patients from this group sufferedsignificant co-morbidities including hypertension (4),coronary artery disease (4), history of myocardialinfarction (2), COPD (1) and diabetes (1). Two patients

Eur J Vasc Endovasc Surg 28, 442–448 (2004)

doi: 10.1016/j.ejvs.2004.06.008, available online at http://www.sciencedirect.com on

*Corresponding author. J. Szmidt, Department of General, Vascularand Transplant Surgery, Banacha 1a, 02-097 Warszawa, Poland.

1078–5884/040442+ 07 $35.00/0 q 2004 Elsevier Ltd. All rights reserved.

had also occlusive iliac disease. Patient characteristicsare shown in Table 1.

The aneurysms were detected clinically (1), orincidentally on plain X-ray (2), abdominal ultrasound(1) or echocardiography (2). In all cases contrast-enhanced thoracoabdominal spiral computed tom-ography (3 mm slides) were performed to measureabdominal and thoracic aneurysm diameters withevaluation for stentgraft implantation. Three dimen-sional reconstruction and angio-CT were performed(Fig. 1). In addition in two cases digital subtractionangiography was performed to attain a clearermorphology of the aortic arch. The indication for acombined procedure was a diagnosed descendingTAA and AAA with technical contraindications forendovascular treatment or no significant risk factorsfor open abdominal aortic surgery (patient nos. 1 and5). All thoracic aneurysms began below the leftsubclavian artery ostium. All except one abdominalaneurysm were infrarenal, with one suprarenal aneur-ysm involving the celiac trunk and superior mesen-teric artery. Preoperative measurements are shown inTable 2.

For TAA exclusion, Talent (Medtronic) straight tubedevices were used. The graft length exceeded theaneurysm length by approximately 3–4 cm anddiameter oversizing was 10–15% (4–6 mm). In twopatients low molecular weight heparin was adminis-tered for 5 days preoperatively. Prior to surgery,informed consent was obtained from all patients forthoracotomy. The patients were prepared and drapedas for thoracoabdominal surgery. All procedures wereperformed in the operative theatre under generalanesthesia. In all cases a transperitoneal abdominalmidline approach was used. After heparinization(70 IU/kg), aortic cross-clamping was performed inthe infrarenal aortic segment except in the patient witha suprarenal aneurysm. In all patients a bifurcatedgelatin-coated Dacron prosthesis (Uni-graft; Braun)was used. After the upper and contralateral limbanastomosis was completed, the aorta was de-clamped and through the ipsilateral limb of thevascular prosthesis a Talent straight tube graft wasplaced under fluoroscopic guidance (Fig. 2). Finalangiography revealed complete exclusion of thoracicaneurysm with no endoleak (Fig. 3). After all catheterswere removed the ipsilateral limb was completed.Abdominal wall closure completed surgery and thepatient was transferred to intensive care unit.

Results

In one case the AAA involving the celiac trunk, Table

1.Patientch

aracteristics

Patient

Age

Sex

Coronary

disease

present

History

ofMI

Hypertension

Cereb

rovascu

lar

disease

COPD

Diabetes

Ren

aldysfunction

Obesity

Smoking

High

lipid

level

Occl.

iliacdis.

Preoperative

coag

ulopathy*

164

MNo

No

No

No

No

No

No

No

Yes

Yes

No

No

272

MYes

yes

No

No

No

No

No

No

No

No

No

No

377

FYes

No

Yes

No

No

Yes

No

Yes

Yes

Yes

Yes

Yes

473

MYes

Yes

Yes

Yes

No

No

No

Yes

No

Yes

Yes

No

569

FNo

No

Yes

No

No

No

No

No

Yes

Yes

No

No

667

MYes

No

Yes

No

Yes

No

No

No

Yes

No

No

Yes

Overall

702F

/4M

4/6

2/6

4/6

1/6

1/6

1/6

0/6

2/6

4/6

4/6

2/6

2/6

MI,myocardialinfarction;COPD,ch

ronic

obstructivepulm

onarydisease.

*Ifpresentlow

molecu

larweighthep

arin

was

administered5day

spreoperatively.

Simultaneous Endovascular Exclusion of Thoracic Aortic Aneurysm 443

Eur J Vasc Endovasc Surg Vol 28, October 2004

superior mesenteric artery and renal arteries. In thispatient an intraoperative coagulopathy developedwhich required plasma and blood transfusion andrecombinant human coagulation factor VIIa. Twohours after primary abdominal closure a relaparotomywas performed due to persistent intra-abdominalhemorrhage. Intensive management with blood trans-fusion, recombinant human coagulation factor VIIaand abdominal packing was ineffective and the patientdied 1 h after the second operation.

In all remaining cases, after a one day ICU stay thepatient returned to the Department ward. Pre-dis-charge CT-scan revealed complete thoracic aneurysmexclusion and no endoleak (Fig. 4). No other earlypostoperative complications occurred, in particularthere were no cases of spinal cord ischemia. In thefollow-up period (8–23 months) CT-scans wereperformed on the third, sixth and 12th monthspostoperatively. We detected one type I endoleak dueto thoracic stentgraft migration in a 6 months CT scan,which was treated by implanting an additionalproximal stentgraft segment. No other types of

endoleak were observed. There were no migration,aneurysm expansion, and any other complicationsassociated with thoracic stentgraft placement orabdominal aneurysmectomy. No neurological defectswere observed in this follow-up time. Detailed resultsare shown in Table 3.

Discussion

Since the first endovascular repair of a thoracic aorticaneurysm in 19926 there has been a significant increasein the numbers and indications for stentgraft implan-tation for diseases of the descending aorta. Thisprocedure has rapidly become a valuable alternativefor thoracic aneurysm treatment.6–9 If the patient isconsidered to be a candidate for endovascular treat-ment, careful assessment of TAA morphology shouldbe performed. The aneurysm should not exceed theleft subclavian artery proximally and there should bean adequate landing zone distally withoutinvolvement of major aortic branches. However,

Fig. 1. CT of patient with TAA (A) and AAA (B) with 3D angio-reconstruction (C).

J. Szmidt et al.444


multifenestrated devices may allow for a more wide-spread use of stentgafts in aneurysms involvingcollateral vessels.4

There is a very little data available for combinedthoracic and abdominal aneurysm repair. Accordingto Moon et al. historically, there were several ways ofsurgical treatment of multilevel aortic aneurysms.2

Simultaneous thoracic and abdominal aneurysmrepair is a challenging surgical procedure, which canalso be performed through separate incisions. Theoperation can be staged in time, and the order shouldbe determined in accordance to aneurysm size andT

able

2.Preoperativemeasu

rements

ofAAA

andTAA

accordingto

CT-scan

AAA

TAA

Patient

Diameter

Ren

ala.

involvem

ent

Proxim

alneck

diameter

Proxim

alnecklength

Proxim

alneck

angulation

Iliaca.

involvem

ent

Significant

iliactortuosity

Feasible

for

endovascrepair

Diameter

Len

gth

Proxim

alnecka

diameter

Proxim

alneckalength

145

bNo

2450

Yes

(608)

Right

common

No

Yes

6197

2913

5

265

No

2128

No

No

Yes

No

9110

431

423

51No

248

Yes

(908)

No

No

No

6521

034

164

74Yes

––

–No

No

No

8764

3513

75

69No

2431

No

No

No

Yes

7353

3114

26

71No

2247

Yes

(808)

Both

common

No

No

5957

3224

Alldim

ensionsarein

mm.

aas

measu

redfrom

theleftsu

bclav

ianartery

ostium.

bSymptomatic

AAA.

Fig. 2. Thoracic stentgraft placement through the limb of theabdominal vascular prothesis.



symptoms. Crawford suggested an initial repair of thethoracic aneurysm in asymptomatic patients.10,11 Onthe other hand 30% of deaths after descending thoracicaneurysm repair is associated with coexistinguntreated infrarenal aneurysm rupture.12 In accord-ance with this data, Crawford performed simul-taneous surgery in patients who continued to dowell in the operating room after the first replacement.The mortality rate for such a procedure was 10%.11 It isalso possible to exclude coexisting TAA and AAA bymeans of thoracic and abdominal stentgrafts. This canbe performed simultaneously or subsequently and is aviable alternative for high risk patients.4 According tomany authors there is no reason for endovascularAAA repair in patients without significant risk factors.In our opinion in patients with multilevel aneurysmalaortic disease the choice of treatment of the concomi-tant AAA should be the same as in patients with AAAonly. The presence of TAA should not modify thetreatment method of the AAA.

Eton reports a case of thoracic stentgraft implan-tation two weeks after open abdominal aneurysmect-omy in a patient with a suspected mycotic thoracicaneurysm.8 Nevertheless if there is no contraindica-tion, both aneurysms should be excluded simul-taneously. This seems a much simpler approach,with the straight tube thoracic graft inserted throughthe limb of the abdominal prosthesis, with noadditional groin incision.

When considering patients with thoracoabdominal

aneurysms it is obligatory to evaluate the patient’scardiopulmonary status. Many patients because oftheir poor cardiopulmonary reserve can still beconsidered for a combined procedure where theywould be otherwise unfit for open thoracotomy. In ourseries at least in two patients open thoracotomy couldnot be performed due to poor cardiopulmonary status.

A serious problem following endovascular andopen repair of thoracic aortic aneurysms is spinalcord ischemia. According to current literature thecomplication rates are equal in both methods oftreatment. Steroids, hypothermia, cerebrospinal fluiddrainage and prevention of hypertension may beoffered to lower the risk of this complication. Overall,the rate of this complication has been shown to rangebetween 0 and 21%.3,4,13–15

The spinal cord is predominantly supplied with

Fig. 3. Final intraoperative angiography of thoracic aorta-complete exclusion of the aneurysm with no endoleak.

Fig. 4. Pre-discharge CT-scan 3D reconstruction of the aorta.

J. Szmidt et al.446


blood through the Adamkiewicz artery and also bythoracic intercostal arteries, which are usually throm-bosed through the aneurysm. Due to this fact thesebranches are very rarely reimplanted during opensurgery.16 In our study all grafts were placed relativelyhigh. Because of this placement and the short graftlength there was little risk in covering the Adamkie-wicz artery and therefore no need to use spinal cordprotection.

In conclusion, endovascular treatment of thoracicaortic aneurysm combined with a simultaneous openabdominal aneurysmectomy is an efficient and rela-tively safe treatment modality in patients with TAAand AAA disqualified from endovascular repair. Thefact that thoracotomy is not a necessity significantlylowers the complication rate after this procedure.However, long-term follow-up on a larger group ofpatients is necessary to assess the durability andeffectiveness of this method of therapy.

References

1 Svensson LG,Crawford ES,Hess KR et al. Experience with 1509patients undergoing thoracoabdominal aortic operations. J VascSurg 1993; 17:357–368.

2 Moon MR, Mitchell RS, Dake MD et al. Simultaneousabdominal aortic replacement and thoracic stent-graft placementfor multilevel aortic disease. J Vasc Surg 1997; 25:332–340.

3 Ballard JL, Abou-Zamzam AM, Teruya TH. Type III and IVthoracoabdominal aortic aneurysm results of a trifurcated/twograft technique. J Vasc Surg 2002; 36:211–216.

4 Meguid AA, Bove PG, Long GW et al. Simultaneous stent-graftrepair of thoracic and infrarenal abdominal aortic aneurysms.J Endovasc Ther 2002; 9(2):165–169.

5 Gloviczki P, Pairolero P, Welch T et al. Multiple aorticaneurysms: the results of surgical management. J Vasc Surg1990; 11:19–28.

6 Dake MD, Miller DC, Semba CP et al. Transluminal placementof endovascular stent-grafts for the treatment of descendingthoracic aortic aneurysms. NEJM 1994; 331:1729–1734.

7 Saccani S, Nicolini F, Beghi C et al. Thoracic aortic stents: acombined solution for complex cases. Eur J Vasc Endovasc Surg2002; 24:423–427. doi:10.1053/ejvs.2002.1687.

8 Eton D, Terramani T, Katz M. Staged thoracic and abdominalaortic aneurysm repair using stent graft technology and surgeryin a patient with acute renal failure. Ann Vasc Surg 2000; 14:114–117. doi: 10.1007/S100169910021.

9 Orend KH, Scharrer-Palmer Z, Kapfer X et al. Endovasculartreatment in diseases of the descending thoracic aorta: 6-yearresults of a single center. J Vasc Surg 2003; 37:91–99.

10 Crawford ES, DeNatale RW. Thoracoabdominal aortic aneur-ysm: observations regarding the natural course of the disease.J Vasc Surg 1986; 3:578–582.

11 Crawford ES. Aortic aneurysm: a multifocal disease. Arch Surg1982; 117:1393–1400.

12 Crawford ES,Walker HSJ, Saleh SA et al. Graft replacement ofaneurysm in descending thoracic aorta: results without bypass orshunting. Surgery 1981; 89:73–85.

13 Graveraux EC, Faries PL, Burks JA et al. Risk of spinal cordischemia after endograft repair of thoracic aortic aneurysms.J Vasc Surg 2001; 34:997–1003.

14 Azizzadeh A, Huynh TT, Miller CC et al. Postoperative riskfactors for delayed neurologic deficit after thoracic and thor-T

able

3.Operativedata

andresu

lts

Patient

Number

ofthoracicsten

tgraft

segmen

tsused

Intrao

per.

endoleak

Typeofab

dominal

distal

anastomosis

Durationof

procedure

(min)

Bloodlost

(ml)

Neu

rologic

defi

cit

30-day

sresu

lts

Follow-up

(months)

Complicationsin

follow-up

12

No

Comm.iliac

170

800

No

Cured

23None

22

No

R-comm.iliacL-ext.iliaca

200

1000

No

Cured

22None

32

No

Ext.iliaca

240

700

No

Cured

19None

41

No

Comm.iliac

330

5000

–Diedb

––

51

No

Comm.iliac

150

500

No

Cured

11None

62

Yes

cext.iliacd

180

1200

No

Cured

8Endoleak

typeIin

6thmonth

aDueto

severeatherosclerosis.

bDiedduringreoperationdueto

persisten

thaemorrhag

e.c Treated

byad

ditional

sten

tgraftsegmen

tplacemen

t.dDueto

aneu

rysm

alcommoniliacarteries.



acoabdominal aortic aneurysm repair: a case-control study. J VascSurg 2003; 37:750–754.

15 Kuniyoshi Y, Koja K,Miyagi K et al. Prevention of postoperativeparaplegia during thoracoabdominal aortic surgery. Ann ThoracSurg 2003; 2003(76):1477–1484. doi: 10.1016/S0003-4975(03)00871-3.

16 Jacobs MJ, de Moll BA, Elenbaas T et al. Spinal cord blood

supply in patients with thoracoabdominal aortic aneurysms.

J Vasc Surg 2004; 35(30):37. doi: 10.1067/mva.2002.120041.

Accepted 7 June 2004

Available online 29 July 2004

J. Szmidt et al.448


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Simultaneous Endovascular Exclusion of Thoracic Aortic Aneurysm with Open Abdominal Aortic Aneurysm Repair