Rimmer, J.

Wolfe, J.H.N.

Elsevier - Publisher Connector 

SHORT REPORT
Type III Thoracoabdominal Aortic Aneurysm Repair:
A Combined Surgical and Endovascular Approach
J. Rimmer and J. H. N. Wolfe*
Regional Vascular Unit, St Mary’s Hospital, London, UK
Introduction
Thoracoabdominal aortic aneurysm (TAAA) repair is a
high-risk procedure and thoracic endovascular stent-
ing has encouraging morbidity and mortality. We
report a case of Type III TAAA repair in a patient with
previous abdominal and thoracic aortic surgery, using
a combined surgical and endovascular approach.
This innovative method is a particularly attractive
option in ‘redo’ operations such as this since it
significantly reduces the extent of dissection and
avoids thoracotomy.
Case Report
A 49 year old gentleman underwent elective infra-
renal abdominal aortic aneurysm (AAA) repair in
1998; he also had a Type B dissection. In 1999 he had a
6.5 cm upper descending thoracic aortic aneurysm
repaired. Follow-up CT revealed a 9.0 cm dilatation of
the intervening native aorta (Fig. 1) with bilateral iliac
aneurysms (3.0 and 4.5 cm).
Risk factors were hypertension and smoking. No
genetic cause for his multiple aneurysms was found but
there was histological evidence of medial degeneration.
Examination revealed a non-tender epigastric aneurysm
and a full complement of left sided infra-inguinal pulses,
associated with a left popliteal aneurysm. On the right
there was a thrombosed popliteal aneurysm. Cardiac
and respiratory status were satisfactory and renal
function was normal.
He underwent TAAA repair and bilateral iliac
aneurysm repair with revascularisation of the visceral
and renal arteries (Fig. 2) and subsequent endoluminal
stent repair. Firstly the iliac aneurysms were repaired
with a bifurcated Dacron graft. The proximal end was
anastamosed end-to-end with the distal end of the
previous infra-renal graft, and the distal limbs end-to-
end with the iliac bifurcations. A second bifurcation
graft was then anastomosed end-to-side to the anterior
aspect of the implanted graft and two 8 mm Dacron
grafts anastomosed either side. Visceral vessels were
then revascularised (superior mesenteric, coeliac and
renal arteries). Once these anastomoses were complete
the vessel origins were ligated to eliminate competi-
tive flows. A further 8 mm sidearm was added to the
graft for endovascular access. A guidewire was
inserted via the right brachial artery to catheterise
the true lumen of the thoracic aorta and prevent
deployment in the false lumen. Four Talent devices
were then placed, via the graft sidearm, to exclude the
aneurysm sac. Good placement was obtained; on-table
completion angiography showed no endoleaks.
He spent four days in intensive care. On the sixth
post-operative day he underwent fasciotomies for
compartment syndrome of his right leg (in which a
thrombosed popliteal aneurysm pre-existed) and the
leg made a full recovery.
Discussion
TAAA repair remains a considerable challenge1 and
techniques that reduce the extent of the surgery are to
be encouraged. These patients usually have signifi-
cantly co-morbidity and redo surgery further com-
pounds the problem. Thoracic endovascular stents
have produces encouraging initial results (Dake)2 but
Eur J Vasc Endovasc Surg 26, 677–679 (2003)
doi: 10.1016/S1078-5884(03)00299-5, available online at http://www.sciencedirect.com on
*Corresponding author. Mr John H. N. Wolfe, Regional Vascular
Unit, St Mary’s Hospital, Praed Street, London W2 1NY, UK.
1078–5884/03/060677 + 03 $35.00/0 q 2003 Elsevier Ltd. All rights reserved.
Fig. 1. CT scan showing a 9 cm dilatation of the native aorta between thoracic and abdominal grafts.
Fig. 2. Schematic representation of the thoracoabdominal aortic aneurysm repair. (A) The pre-operative situation; (B)
following repair of the iliac aneurysms and revascularisation of the visceral arteries and renal arteries; (C) the stent deployed
through the aneurysmal thoracoabdominal segment through a side arm.
J. Rimmer et al.678
Eur J Vasc Endovasc Surg Vol 26, December 2003
have been limited by the need for visceral revascular-
isation.
Paraplegia is a serious complication when the
whole thoracic aorta is repaired and endovascular
repair appears to reduce this risk. There are at least
two potential reasons for this apparently inexplicable
observation. The first is the proximal deployment of
the stent leaving the lower thoracic intercostal artery
uncovered and supplied through back-filling through
the lower part of the false lumen. The second is the
reduced stress response that may protect the cord from
a spinal compartment syndrome (paraplegia some-
times still occurs in the presence of a spinal drain).3
Our patient had not only had previous AAA repair
but also thoracic aortic surgery. This presented the
added problem of a redo-thoracotomy (which is
associated with significant blood loss from the
denuded pleural cavity). Endovascular repair avoided
the need for this incision, and thereby reduced
potential morbidity. Open surgical repair of the
abdominal component allowed visceral revascularisa-
tion prior to the deployment of the graft and, as a
result, no visceral ischaemia time. It also provided a
conduit for radiological access via which the stents
were deployed.
The immediate recovery was excellent other than
the predictable ischaemia of the right leg, which
recovered. The avoidance of paraplegia was a relief
and was unexplained. Our only suggestion is that
collaterals had developed following the previous
aortic surgery so that the spinal cord was no longer
dependent upon the remaining intercostal arteries.
Certainly the presence of thrombus in the remaining
aneurysmal segment of the thoracic aorta suggests that
these intercostals may have already been occluded.
Few cases of combined endovascular and surgical
repair have been documented,4 – 6 and we found no
reports involving aneurysmal native aorta between
two grafts. This approach allows treatment of patients
whose co-morbidity may have previously made
them unsuitable for TAAA repair, and reduces the
morbidity and mortality rates of these high-risk
procedures.
References
1 Gilling-Smith GL, Worswick L, Knight PF, Wolfe JH, Mans-
field AO. Surgical repair of thoracoabdominal aortic aneurysm:
10 years’ experience. Br J Surg 1995; 82(5): 624–629.
2 Dake MD. Endovascular stent-graft management of thoracic
aortic diseases. Eur J Radiol 2001; 39: 42–49.
3 Gravereaux EC, Faries PL, Burks JA, Latessa V, Spielvogel D,
Hollier LH, Marin ML. Risk of spinal cord ischaemia after
endograft repair of thoracic aortic aneurysms. J Vasc Surg 2001;
34(6): 997–1003.
4 Agostinelli A, Saccani S, Budillon AM, Nicolini F, Beghi C,
Larini P, Gherli T. Repair of coexistent infrarenal and thoraco-
abdominal aortic aneurysm: combined endovascular and open
surgical procedure with visceral vessel relocation. J Thorac
Cardiovasc Surg 2002; 124(1): 184–185.
5 Quinones-Baldrich WJ, Panetta TF, Vescera CL, Kashyap VS.
Repair of type IV thoracoabdominal aneurysm with a combined
endovascular and surgical approach. J Vasc Surg 1999; 30(3):
555–560.
6 Saccani S, Nicolini F, Beghi C, Marcato C, Uccelli M, Larini
P, Budillon AM, Agostinelli A, Gherli T. Thoracic aortic stents:
a combined solution for complex cases. Eur J Vasc Endovasc Surg
2002; 24: 423–427. doi:10.1053/ejvs.2002.1687.
Accepted 12 May 2003
Type III Thoracoabdominal Aortic Aneurysm Repair: A Combined Surgical and Endovascular Approach 679
Eur J Vasc Endovasc Surg Vol 26, December 2003


Type III Thoracoabdominal Aortic Aneurysm Repair: A Combined Surgical and Endovascular Approach 

file:///data/core-remote/dit/data/elsevier/pdf/72b/aHR0cDovL2FwaS5lbHNldmllci5jb20vY29udGVudC9hcnRpY2xlL3BpaS9zMTA3ODU4ODQwMzAwMjk5NQ==.pdf

Type III Thoracoabdominal Aortic Aneurysm Repair: A Combined Surgical and Endovascular Approach

Abstract

Similar works

Full text

Available Versions

Elsevier - Publisher Connector