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FALSE LUMEN ACCESS FOR TRANS-SEPTAL TEVAR IN A 10-CM DISSECTING THORACOABDOMINAL AORTIC ANEURYSM

Open AccessPublished:November 10, 2021DOI:https://doi.org/10.1016/j.jvscit.2021.10.013

      Abstract

      Endovascular treatment of the chronically dissected aorta can be particularly challenging due to unending variation in post-dissection configurations. Traditionally, basic principles of thoracic endovascular aortic repair (TEVAR) rely on bilateral femoral access and deployment of a stent-graft within the true lumen. We describe here a case of trans-septal TEVAR in a patient with complex chronic residual type B aortic dissection (1,10) with dilation up to 10cm in the context of a chronically occluded right external iliac artery, and a left iliofemoral system supplied by the false lumen.

      Keywords

      Background

      Thoracic endovascular aortic aneurysm repair (TEVAR) is now the first-line treatment for descending thoracic aortic aneurysm and dissection

      Scali ST, Goodney PP, Walsh DB, Travis LL, Nolan BW, Goodman DC, et al. National trends and regional variation of open and endovascular repair of thoracic and thoracoabdominal aneurysms in contemporary practice. Journal of Vascular Surgery 2011;53(6):1499-1505. DOI: https://doi.org/10.1016/j.jvs.2011.02.014.

      Jones DW, Goodney PP, Nolan BW, Brooke BS, Fillinger MF, Powell RJ, et al. National trends in utilization, mortality, and survival after repair of type B aortic dissection in the Medicare population. Journal of Vascular Surgery 2014;60(1):11-19.e1. DOI: https://doi.org/10.1016/j.jvs.2013.12.047.

      Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, et al. Editor's Choice – Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). European Journal of Vascular and Endovascular Surgery 2017;53(1):4-52. DOI: https://doi.org/10.1016/j.ejvs.2016.06.005.

      Kang WC, Greenberg RK, Mastracci TM, Eagleton MJ, Hernandez AV, Pujara AC, et al. Endovascular repair of complicated chronic distal aortic dissections: Intermediate outcomes and complications. The Journal of Thoracic and Cardiovascular Surgery 2011;142(5):1074-1083. DOI: https://doi.org/10.1016/j.jtcvs.2011.03.008.

      . Basic criteria for TEVAR eligibility include adequate proximal and distal landing zones, in addition to adequate ilio-femoral access

      Upchurch GR, Escobar GA, Azizzadeh A, Beck AW, Conrad MF, Matsumura JS, et al. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. Journal of Vascular Surgery 2021;73(1, Supplement):55S-83S. DOI: https://doi.org/10.1016/j.jvs.2020.05.076.

      . Cases of aortic dissection can be particularly challenging due to the presence of multiple fenestrations and dual lumens. We report here a case of trans-septal TEVAR in a patient with complex chronic residual type B aortic dissection (1,10) with dilation up to 10cm after previous ascending aortic replacement for acute type A dissection, in addition to chronic complete occlusion of the right external iliac artery, and a left iliofemoral system supplied by the false lumen. The patient described here has consented to publication of all case details and associated images.

      Case Report

      This is a 49-year-old female smoker with history of hypertension, coronary artery disease, coronary artery bypass graft (CABG), renal cell carcinoma, nephrectomy, end stage renal disease (ESRD) on hemodialysis, and stroke with residual left lower extremity paralysis. She had previously undergone ascending aortic replacement for acute type A dissection 14 years prior. On presentation, computed tomography angiography (CTA) demonstrated residual dissection of the arch and entire thoracoabdominal aorta with aneurysmal degeneration measuring 10-cm in maximum diameter (Figure 1A). CTA also revealed complete occlusion of the right external iliac artery and a left iliofemoral system supplied entirely by the false lumen (Figures 1B, C).
      Figure thumbnail gr1
      Figure 1A) Chronic residual dissection of the arch, descending and abdominal aorta with aneurysmal dilation up to 10 cm of the distal descending thoracic aorta. B,C) Occluded right external iliac artery, patent right internal artery; left mid-to-distal common and external iliac arteries supplied entirely by the false lumen. The arrow in panel B points to a spot of calcium representative of the only remnant of true lumen in the distal left common iliac artery; contrast enhancement is visualized in the false lumen.
      In conjunction with the cardiac team, a multi-stage approach was devised. This consisted of A) total arch replacement with great vessel debranching; B) left carotid-subclavian bypass; and C) TEVAR (0,5) with coil embolization of the left subclavian artery. Additional interventions to address the perivisceral and infrarenal portions of the aorta would be contingent on the result of aortic remodeling following these initial interventions. Noted challenges would include a third-time redo sternotomy and lack of normal femoral access. After extensive discussion with the patient, the cardiac surgery team proceeded with stage A of the operative plan. After full recovery, the patient was brought back 5 months later for stages B and C. Left carotid-subclavian was performed without complication, and two days later, the patient was brought back for elective TEVAR.
      The patient was brought to the hybrid operating room suite; a lumbar drain was placed, and continuous neuromonitoring via somatosensory evoked potentials (SSEP) and electroencephalogram (EEG) was initiated. The patient was placed under general anesthesia. The left common femoral artery, known to be supplied by the false lumen, was surgically exposed and accessed via micropuncture technique. A 5-french sheath was inserted and an angled Glidewire and Bernstein catheter were passed into the false lumen of the abdominal aorta. Flush abdominal aortography demonstrated several large fenestrations (Figure 2A). Under roadmap guidance, the proximal-most fenestration was crossed using the angled Glidewire and a Berenstein catheter, allowing access into the true lumen, which was then confirmed via intravascular ultrasound (IVUS) and angiography (Figures 2B, C). Serial dilation of the fenestration up to 18-french was performed. A 20-french Gore DrySeal sheath was then inserted across the fenestration with the tip positioned in the true lumen (Figure 3A-C). Through this, a Lunderquist wire was positioned in the ascending aorta, and a buddy wire was inserted to allow for positioning of a pigtail catheter, given the occluded contralateral iliofemoral system. Ascending and arch angiography was performed, redemonstrating the dilated descending thoracic aorta and significant false lumen filling (Figure 4A). A Medtronic Navion stent graft 34 x 34 x 223mm was deployed just past the take-off of the debranched vessels in Zone 0, followed by a 34 x 34 x 223mm distal extension piece which was landed in Zone 5 at the level of the celiac trunk. Balloon angioplasty of all seal and overlap sites was performed. Completion angiography demonstrated immediate augmentation of the true lumen with patent cervical and visceral vessels, and no antegrade flow into the false lumen (Figure 4B). Following this, the left brachial artery was accessed using micropuncture technique under ultrasound guidance. We then proceeded to coil the origin of the left subclavian artery, taking care to maintain patency to the vertebral artery.
      Figure thumbnail gr2
      Figure 2A) Angiography demonstrates numerous large fenestrations connecting the true and false lumen. B) Under roadmap guidance, the proximal-most fenestration was crossed using an angled Glidewire and a Berenstein catheter, allowing access into the true lumen. C) Catheter placement in the true lumen was confirmed via angiography.
      Figure thumbnail gr3
      Figure 3Serial dilation of the fenestration up to 18-grench was performed. A) Dilators were inserted via the left femoral access site and B) passed across the fenestration into the true lumen. C) A 20-french Gore DrySeal sheath was then inserted across the fenestration with the tip positioned in the true lumen.
      Figure thumbnail gr4
      Figure 4A) Ascending and arch angiography demonstrated the dilated descending thoracic aorta and significant false lumen filling. B) Completion angiography demonstrated immediate augmentation of the true lumen with patent cervical and visceral vessels, and no antegrade flow into the false lumen.
      Post-operative recovery was largely uncomplicated. The patient did have an extended stay due to several days of agitation; she was discharged on post-operative day 11 with no new deficits and mental status at baseline. Nine-month follow-up CTA demonstrated intact repair with positive aortic remodeling, augmentation of the true lumen distally and near-complete thrombosis of the false lumen with residual retrograde filling from the visceral vessels (Figure 5A, B).
      Figure thumbnail gr5
      Figure 5A,B) Sagittal and coronal views, respectively, of the repair at 9 months. Of note is the significantly augmented true lumen at the level of the aortic hiatus, and thrombosis of the false lumen in the descending thoracic aorta with a blush of contrast at the transition into the abdominal aorta, indicating residual retrograde flow from the perivisceral segment.

      Discussion

      TEVAR has become the preferred method of treatment for thoracic aortic aneurysms

      Scali ST, Goodney PP, Walsh DB, Travis LL, Nolan BW, Goodman DC, et al. National trends and regional variation of open and endovascular repair of thoracic and thoracoabdominal aneurysms in contemporary practice. Journal of Vascular Surgery 2011;53(6):1499-1505. DOI: https://doi.org/10.1016/j.jvs.2011.02.014.

      Jones DW, Goodney PP, Nolan BW, Brooke BS, Fillinger MF, Powell RJ, et al. National trends in utilization, mortality, and survival after repair of type B aortic dissection in the Medicare population. Journal of Vascular Surgery 2014;60(1):11-19.e1. DOI: https://doi.org/10.1016/j.jvs.2013.12.047.

      Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, et al. Editor's Choice – Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). European Journal of Vascular and Endovascular Surgery 2017;53(1):4-52. DOI: https://doi.org/10.1016/j.ejvs.2016.06.005.

      Kang WC, Greenberg RK, Mastracci TM, Eagleton MJ, Hernandez AV, Pujara AC, et al. Endovascular repair of complicated chronic distal aortic dissections: Intermediate outcomes and complications. The Journal of Thoracic and Cardiovascular Surgery 2011;142(5):1074-1083. DOI: https://doi.org/10.1016/j.jtcvs.2011.03.008.

      . In cases of chronic dissection, aneurysmal dilation is typically secondary to persistent flow in the false lumen. Thus, the goal in treatment is to augment the true lumen by preferentially redirecting flow, inducing false lumen thrombosis, and encouraging positive aortic remodeling. This is commonly accomplished by coverage of the entry tear via endograft placement through bilateral groin access. While alternative access methods have been described, the feasibility of TEVAR has traditionally been contingent on adequate femoral access
      • Botta L.
      • Bruschi G.
      • Fratto P.
      • Margari V.
      • Solcia M.
      • Borgia F.
      • et al.
      Direct Transaortic TEVAR: An Alternative Option for Selected Patients With Unsuitable Peripheral Access.
      ,
      • Venturini J.M.
      • Milner R.
      • Shah A.P.
      Percutaneous transapical access to facilitate complex thoracic endovascular aortic repair.
      .
      In this case, the patient had an occluded right iliofemoral system, limiting us to unilateral access via the left iliofemoral system, which was supplied by the false lumen. While techniques describing intentional endograft placement within the false lumen (FLIP) have previously been reported, initial access via the false lumen for endograft delivery has not been described
      • Quinones-Baldrich W.J.
      • Saleem T.
      • Oskowitz A.
      Infrarenal aortic repair with or without false lumen intentional placement of endografts for hybrid management of complex aortic dissection.
      . Furthermore, with our entry point in the false lumen, it was critical that we gain access to the true lumen for endograft placement. Reports have described manual creation of fenestrations via a variety of techniques, but we emphasize here the use of pre-existing fenestrations when able to minimize the possibility of complications
      • Levack M.M.
      • Kindzelski B.A.
      • Miletic K.G.
      • Vargo P.R.
      • Bakaeen F.G.
      • Johnston D.R.
      • et al.
      Adjunctive endovascular balloon fracture fenestration for chronic aortic dissection.
      • Li C.
      • Xu P.
      • Hua Z.
      • Jiao Z.
      • Cao H.
      • Liu S.
      • et al.
      Early and midterm outcomes of in situ laser fenestration during thoracic endovascular aortic repair for acute and subacute aortic arch diseases and analysis of its complications.
      • Tse L.W.
      • Lindsay T.F.
      • Roche-Nagle G.
      • Oreopoulos G.D.
      • Ouzounian M.
      • Tan K.T.
      Radiofrequency in situ fenestration for aortic arch vessels during thoracic endovascular repair.
      . Serial dilations allowed us to safely pass a large-bore sheath for subsequent endograft delivery.
      An alternative method of access that may be considered is construction of a right-sided iliac conduit, as the right common iliac artery was patent and not dissected. This would allow in-line access to the true lumen, an option to revascularize the hypogastric artery for additional spinal cord protection and allow reperfusion of the extremity. In this case, the patient was asymptomatic from the chronic right iliofemoral occlusion, already wheelchair-bound from her left lower extremity paralysis, mildly contracted on the right side, and still healing superficial ulcerations on her right hip and sacrum due to prolonged immobility after her debranching surgery. For these reasons, we felt that the left groin was a more suitable access option.
      In the context of complex thoracic aortic disease, many patients are not ideal candidates for open surgical repair due to concomitant comorbid conditions. While the advent of TEVAR has allowed for a number of these patients to undergo treatment, there remains a subset with particularly challenging anatomy that may not initially appear to be amenable to TEVAR. Chronic dissections have proven to be particularly difficult especially when there is branch vessel involvement. We add here the use of natural fenestrations and false lumen femoral access as additional tools for the armamentarium in treatment of patients with complex aortic dissections. Pre-operative planning should include a well-timed CTA to identify true and false lumen anatomy. A diagnostic angiogram either as a separate session or at the time of operation can confirm CTA findings and potentially identify additional aortic anatomical features not captured on CTA. The ability to customize treatment to each patient is critical when considering aortic intervention. In this case, we were able to take advantage of existing features of the dissection to successfully deploy an endograft with early evidence of positive aortic remodeling.

      References

      1. Scali ST, Goodney PP, Walsh DB, Travis LL, Nolan BW, Goodman DC, et al. National trends and regional variation of open and endovascular repair of thoracic and thoracoabdominal aneurysms in contemporary practice. Journal of Vascular Surgery 2011;53(6):1499-1505. DOI: https://doi.org/10.1016/j.jvs.2011.02.014.

      2. Jones DW, Goodney PP, Nolan BW, Brooke BS, Fillinger MF, Powell RJ, et al. National trends in utilization, mortality, and survival after repair of type B aortic dissection in the Medicare population. Journal of Vascular Surgery 2014;60(1):11-19.e1. DOI: https://doi.org/10.1016/j.jvs.2013.12.047.

      3. Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, et al. Editor's Choice – Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). European Journal of Vascular and Endovascular Surgery 2017;53(1):4-52. DOI: https://doi.org/10.1016/j.ejvs.2016.06.005.

      4. Kang WC, Greenberg RK, Mastracci TM, Eagleton MJ, Hernandez AV, Pujara AC, et al. Endovascular repair of complicated chronic distal aortic dissections: Intermediate outcomes and complications. The Journal of Thoracic and Cardiovascular Surgery 2011;142(5):1074-1083. DOI: https://doi.org/10.1016/j.jtcvs.2011.03.008.

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