The authors report the case of a 66-year-old male patient diagnosed with a pseudoaneurysm of the distal aorto-aortic anastomosis treated with the inner tubing technique. The patient had been operated on 1 year before when he had an aortic prosthesis implanted as treatment for a ruptured abdominal aortic aneurysm. The inner tubing technique was developed to facilitate the treatment in bifurcated vascular lesions, where endovascular conventional prosthesis is not availabl

Gaspar, Márcio Teodoro da Costa

Mattos, Bruno Vinicius Hortences de

Sofia, Milena Cristina Dias

English

Cadernos Espinosanos (E-Journal)

Autopsy and Case Reports. ISSN 2236-1960. Copyright © 2016. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided article is properly cited.a Surgery Department - Clinica Multiperfil – Luanda – Angola.b Surgery Department - Faculty of Medicine - Universidade de São Paulo - São Paulo/SP – Brazil.c Surgery Division - Hospital Universitário - Universidade de São Paulo - São Paulo/SP – Brazil.Inner tubing technique used for the treatment of anastomotic aneurismMárcio Teodoro da Costa Gaspara, Bruno Vinicius Hortences de Mattosb,  Milena Cristina Dias Sofiac, Grace Carvajal Mulattic, Alex LedermancGaspar MTC, Mattos BVH, Sofia MCD, Mulatti GC, Lederman A. Inner tubing technique used for the treatment of anastomotic aneurism. Autopsy Case Rep [Internet]. 2016;6(2):55-58. http://dx.doi.org/10.4322/acr.2016.032AbstractThe authors report the case of a 66-year-old male patient diagnosed with a pseudoaneurysm of the distal aorto-aortic anastomosis treated with the inner tubing technique. The patient had been operated on 1 year before when he had an aortic prosthesis implanted as treatment for a ruptured abdominal aortic aneurysm. The inner tubing technique was developed to facilitate the treatment in bifurcated vascular lesions, where endovascular conventional prosthesis is not available. Keywords Aortic Aneurysm, Abdominal; Endovascular ProceduresCASE REPORTA 66-year-old male patient—an ex-smoker—who was previously diagnosed with hypertension, dyslipidemia, non-dialytic chronic renal failure, and benign prostate hyperplasia was admitted to the emergency facility with the diagnosis of a juxtarenal abdominal aortic aneurysm rupture. He was submitted to a thoraco-phreno-laparotomy followed by aneurysmectomy and aorto-aortic Dacron prosthesis insertion. Within the first 24 hours of the postoperative period, mesenteric ischemia and abdominal compartment syndrome ensued, which required an extensive enterectomy involving the small bowel until 1.7 m of the Treitz angle, accompanied by proximal enterostomy, distal stump burial, and Bogotá bag peritoneostomy. The abdominal cavity was closed after two revisions. On the twentieth postoperative day, after the last surgical procedure, right lower limb ischemia, caused by decompensated chronic arterial occlusion, required transtibial amputation. The patient was discharged after 55 days of hospitalization. Nearly 1 year after these procedures, he was hospitalized for reconstruction of the intestinal transit and incisional hernioplasty with preperitoneal Marlex mesh.A pseudoaneurysm of the distal aorto-aortic anastomosis was diagnosed by a Doppler ultrasound performed during the 1-year follow-up, which was confirmed by a non-contrasted abdominal computed tomography (CT). The latter detected an infrarenal fusiform aneurysm emerging 8 cm below the renal arteries and extending until the emergence of the iliac Article / Clinical Case ReportAutopsy and Case Reports 2016;6(2):55-58Inner tubing technique used for the treatment of anastomotic aneurism56arteries (7.3 cm in length and 6.1 cm in diameter). An eccentric thrombus and parietal calcifications were present, and a saccular component (3.7 cm in length and 3.7 cm in diameter) extended until the right common iliac artery, as shown in (Figure 1).In light of the imaging findings and clinical data, some therapeutic options were considered, namely: (i) inner tubing or sandwich; (ii) multilayer flow modulator; (iii) aortomonoiliac endografting plus femorofemoral crossover bypass graft; and (iv) open surgery. However, taking into account the multiple previous surgical interventions, the vascular surgeons chose the inner tubing technique, which was performed as follows: (i) a bilateral inguinotomy with isolation of the common, the internal, and the external femoral arteries; (ii) systemic heparinization; (iii) an arteriography identifying the distal prosthesis, and the common internal and external iliac arteries; (iii) the insertion of bilateral rigid guidewire; (iv) a Viabahn endoprostesis kissing placement (13 × 100 left; 10 × 150 right); (v) a control arteriography (a small endoleak on the left side was detected but blood flow was satisfactorily obtained on both sides); (vi) arterial suture with 5-0 prolene; and (vii) suture of the inguinotomies. The procedure was uneventful, without the need for hemoderivatives transfusion. The patient was fed orally on the first postoperative day and was discharged on the second day. Perfusion was promptly fully re-established, which was assured on the ambulatory follow-up by clinical examination. A control CT was done 1 month after the procedure (Figure 2).DISCUSSIONEndovascular treatment of aneurysms represents, beyond question, a great deal of movement in vascular surgery. In the treatment of patients with increasingly severe conditions, the improvement of prostheses and refinement of the endovascular Figure 1. Computed tomography of the abdomen. A - Coronal plane; and B - sagittal plane, showing an aortic aneurysm at the site of the distal aorto-aortic anastomosis.Autopsy and Case Reports 2016;6(2):55-58Gaspar MTC, Mattos BVH, Sofia MCD, Mulatti GC, Lederman A57techniques are accompanied by encouraging results1. Several techniques are available for the treatment of aneurysms2,3,4, but in the case reported herein the inner tubing technique was chosen, which was developed for bifurcation lesions where conventional vascular endoprosthesis are unavailable or the anatomy does not fit the available endoprosthesis5. The aortomonnoiliac endovascular grafting technique would be, indeed, an adequate procedure for this case, but it would involve a higher surgical risk and the requirement of an aortic endoprosthesis that was unavailable in our service. Thus, a straight stent was set in place to create a “proximal neck,” followed by the insertion (within the first stent) of two other parallel stents using the “kissing” maneuver plotting up a branch in each artery bifurcation5. In our patient, since the previous inserted prosthesis was in the aortic position, it was only necessary to complete the technique by deploying the iliac extensions bilaterally. The first prosthesis served as the basis for fixing the new iliac branches.This technique, besides the preservation of vascular bifurcations,5 presents the following advantages: (i) the use of easily available, off-the-shelf, covered stents without the need for individualized customization; (ii) a full approach by inguinotomy without the need for a laparotomy in a previously operated abdomen; (iii) the preservation of two iliac arteries without the necessity of the performance of an aortic-monoiliac graft associated with a femorofemoral crossover bypass; (iv) the preservation of the hypogastric arteries; (v) reduced hospitalization time; and (vi) reduced time of anesthesia. On the other hand, the main early- and mid-term complication of any endovascular procedure/treatment is represented by the proximal and distal endoleaks. In our case, the proximal endoleak was prevented by using an endoprosthesis gauge adapted to fill the whole lumen of the first prosthesis (confirmed by the control image). The distal leak was resolved by the aneurysm remodeling since the endoprostheses were well located into the iliac arteries. The occlusion of an endoprosthesis is another possible complication of this chosen technique. However, the control CT showed an adequate blood flow and the absence of kinking in the endoprostheses.The inner tubing technique seems to be a viable therapeutic option accompanied by a promising outcome, besides being a minimally invasive method for the correction of complex lesions in high-risk patients with a hostile abdomen.5 Larger studies and longer follow-up are still needed to assure promising results in other cases.REFERENCES1. Sakalihasan N, Limet R, Defawe OD. Abdominal aortic aneurysm. Lancet. 2005;365(9470):1577-89. http://dx.doi.org/10.1016/S0140-6736(05)66459-8. PMid:15866312.2. Kafejian O, Ricci JA, Nem JT Jr, Roberti T, Bolanho E. Aneurisma de aorta abdominal: diagnóstico, tratamento cirúrgico e resultados. Cir Vasc Ang. 1988;4:8-15.3. Novero ER, Metzger PB, Angelieri FMR, et al. Correção endovascular do aneurisma da aorta abdominal: análise dos resultados de único centro. Radiol Bras. 2012;45(1):1-6. http://dx.doi.org/10.1590/S0100-39842012000100003.Figure 2. Computed tomography of the abdomen performed three months after the procedure. A - 3D reformation; and B - coronal plane; patency of the endoprosthesis in the iliac arteries position.Autopsy and Case Reports 2016;6(2):55-58Inner tubing technique used for the treatment of anastomotic aneurism584. Araujo AG, Souza FHR, Fernandes FH, Barbosa FP, Jatene JA, Câmara PCG. Tratamento endovascular de aneurisma de aorta abdominal pela técnica de Chaminé. Rev Bras Cardiol Invasiva. 2014;22(4):386-9. http://dx.doi.org/10.1590/0104-1843000000065.5. Lederman A, Saliture FT No, Mioto B No, Bub GL, Lobato MA, Aun R. Inner tubing endograft: a new technique for bifurcation preservation. J Vasc Bras. 2009;8(3):255-8. http://dx.doi.org/10.1590/S1677-54492009005000013.Conflict of interest: NoneSubmitted on: January 5th, 2016 Accepted on: March 31st, 2016Correspondence Márcio Teodoro da Costa Gaspar Hospital Universitário - Universidade de São Paulo (USP) Av. Prof. Lineu Prestes, 2565, Butantã, São Paulo/SP – Brazil CEP: 05508-000 Phone: +55 (11) 94836-3866 E-mail: marcio85gaspar@gmail.com

Inner tubing technique used for the treatment of anastomotic aneurism

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Inner tubing technique used for the treatment of anastomotic aneurism

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