AbstractEur J Vasc Endovasc Surg 25, 185–187 (2003

Abe, T.

Fukada, J.

Kawaharada, N.

Kurimoto, Y.

Morishita, K.

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Stent-grafting for a thoracic aortic aneurysm ruptured into the right pleural cavity 

TECHNICAL NOTE
Stent-grafting for a Thoracic Aortic Aneurysm Ruptured into the
Right Pleural Cavity
Y. Kurimoto, K. Morishita, N. Kawaharada, J. Fukada and T. Abe
Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University, Sapporo 060-8543, Japan
Key Words: Aneurysm rupture; Endovascular repair; Thoracic aortic aneurysm.
Eur J Vasc Endovasc Surg 25, 185±187 (2003)
doi:10.1053/ejvs.2002.1787, available online at http://www.sciencedirect.com onIntroduction
Although outcomes of conventional surgical treat-
ment of descending thoracic aortic aneurysms
(DTAA) have been improved for elective cases, the
results of treatment of ruptured DTAA are still far
from satisfactory.1 Thoracotomy and the use of cardio-
pulmonary bypass are too invasive for some critical
cases of ruptured DTAA. In addition, unilateral ven-
tilation during graft replacement is a major problem
for patients with respiratory failure. Recently, the use-
fulness of stent-grafting as a less invasive method for
managing DTAA has been recognised.2 Satisfactory
results of emergency endovascular stent-grafting in
patients with traumatic thoracic aortic rupture have
been reported.3 We report an unusual case of DTAA
that had ruptured into the right pleural cavity, which
was successfully treated by immediate endovascular
stent-grafting.
Technical Report
A 69-year-old woman presented as an emergency
with dyspnaea and severe back pain. On arrival, her
systolic blood pressure was 80 mmHg and her heart
rate was regular, 120 beats per minute. Following
volume resuscitation, chest computed tomographyPlease address all correspondence to: Y. Kurimoto, Department of
Thoracic and Cardiovascular Surgery, Sapporo Medical University,
Sapporo 060-8543, Japan.
1078±5884/03/020185 03 $35.00/0 # 2002 Elsevier Science Ltd. All(CT) was performed. CT revealed the presence of a
DTAA that had ruptured into the right pleural cavity
(Fig. 1). Blood gas analysis showed PaO2 of 55 mmHg,
despite supplementation with 10 l/min O2, and a
blood haemoglobin concentration of 7.8 mg/dl. Hyp-
oxia was not improved after drainage of 800 ml arter-
ial blood from the right pleural cavity, and so tracheal
intubation was performed. It was decided to perform
endovascular stent-grafting to avoid the risk of hyp-
oxia occurring during unilateral ventilation used in a
conventional operation.
A stent graft was constructed on the basis of findings
in contrasted CT images while the patient was beingFig. 1. Contrast CT revealed mediastinal haematoma and right hae-
mothorax and suggested a rupture of a descending thoracic aortic
aneurysm.
rights reserved.
186 Y. Kurimoto et al.anaesthetised in the operating room. A 30-mm UBE
woven prosthetic vascular graft (Ube Corp., Ube,
Japan), 13 cm in length was placed over 30-mm
Gianturco Z-stents (Cook Inc., Bloomington, IN,
U.S.A.) and held in position with 5-0 polypropylene
tacking sutures. For this purpose, the Z-stents have
been modified and reconnected so as to have a rigid
side and a flexible side longitudinally to enable them to
fit the aortic tortuosity, and they also have a ringed
wire as a stabiliser at a proximal end that prevents
migration of the stent graft during deployment. Graft
construction took 20 min. The stent graft was com-
pressed into a proximal end of an 18-Fr. (i.e., 6 mm)-
long introducer sheath (Cook Inc.). The stent-graft sys-
tem was passed over the guide-wire through an
exposed common femoral artery and positioned at
the desired location as determined by an intraproce-
dural digital subtracted angiogram (DSA). After exact
positioning, the sheath was moved downward and
stent graft deployment was achieved (Fig. 2). Because
there was no endoleakage, balloon dilatation of the
stent graft was not considered necessary. After stent-
grafting, bleeding from the chest tube was greatly
reduced and the tube was removed one day after the
operation. Postoperative blood transfusion was not
required. Although the patient required a ventilator
for 6 days after the operation, the postoperative
course was otherwise uneventful. A CT scan at one
month confirmed exclusion and thrombosis of the
aneurysm.Fig. 2. DSA images show a descending thoracic aortic aneurysm (left s
side).
Eur J Vasc Endovasc Surg Vol 25, February 2003Discussion
There have been few reports of cases in which stent-
grafting was performed for a DTAA that had ruptured
into the pleural cavity.4,5 Moreover, there have been no
previous reports on successful treatment using stent-
grafting of a DTAA that had ruptured into the right
pleural cavity, probably because a rupture into the
right pleural cavity is unusual and because a delay
in diagnosis would result in deterioration of the
patient's condition and thus eliminate stent-grafting
as an option in some cases.6
Although stent-graft for a normal aortic wall has
been shown to be effective for haemostasis in animal
models,7 it is still not clear whether stent-grafting for a
ruptured DTAA is clinically effective. The indication
for stent-grafting must be considered carefully in each
case. Haemorrhagic shock due to a ruptured DTAA
requires immediate haemostasis with thoracotomy
and graft replacement using cardiopulmonary bypass.
Therefore, good candidates for stent-grafting for a
ruptured DTAA are those who are haemodynamically
stable.
Accurate deployment is crucial to obtain good
results of stent-grafting for aortic diseases.8,9 In the
present case, intraprocedural DSA, mild hypotension
(systolic blood pressure of 80 mmHg) induced by
nicardipine hydrochloride, and a stent-graft stabiliser
were employed for accurate deployment of the stent
graft. A stabiliser, which is hung up on an introduceride) and the aneurysm successfully excluded by stent-grafting (right
Stent-grafting for Ruptured Thoracic Aortic Aneurysm 187tip during deployment, is thought to be important in
our procedure. There are still some problems in endo-
vascular stent-grafting for DTAA, such as difficulty of
access and endoleakage. Improved delivery methods
and devices should resolve these problems in the
future.
References
1 Crawford ES, Hess KR, Cohen ES et al. Ruptured aneurysm of
the descending thoracic and thoracoabdominal aorta: analysis
according to size and treatment. Ann Surg 1991; 213: 417±426.
2 Dake M, Miller D, Michell R et al. The `` first generation'' of
endovascular stent-grafts for patients with aneurysms of the
descending thoracic aorta. J Thorac Cardiovasc Surg 1998; 116:
689±704.
3 Lobato AC, Quick RC, Phillips B et al. Immediate endovascular
repair for descending thoracic aorta transection secondary to
blunt trauma. J Endovasc Ther 2000; 7: 16±20.4 Palombi M, Berardi F, Sposato S et al. Endovascular treatment
of a ruptured thoracic aortic aneurysm. Eur J Vasc Endovasc Surg
2000; 19: 101±102.
5 Semba CP, Kato N, Kee ST et al. Acute rupture of the descend-
ing thoracic aorta: repair with use of endovascular stent-grafts.
JVIR 1997; 8: 337±342.
6 Baharloo F, Verhelst R, Collard P et al. Ruptured of aortic
aneurysm with right-sided haemothorax. Eur Respir J 1999; 13:
465±467.
7 Williams DM, Andrews JC, Chee SS et al. Canine model of
acute aortic rupture: treatment with percutaneous delivery of a
covered Z stent-work in progress. JVIR 1994; 5: 797±803.
8 Nienaber CA, Fattori R, Lund G et al. Nonsurgical reconstruc-
tion of thoracic aortic dissection by stent-graft placement. N Engl
J Med 1999; 340: 1539±1545.
9 Thompson CS, Gaxotte VD, Rodriguez JA et al. Endoluminal
stent grafting of the thoracic aorta: initial experience with the
gore excluder. J Vasc Surg 2002; 35: 1163±1170.
Accepted 10 June 2002Eur J Vasc Endovasc Surg Vol 25, February 2003


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Stent-grafting for a thoracic aortic aneurysm ruptured into the right pleural cavity

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