Tevar for adult false aneurysm following open repair of aortic coartaction

Authors: Mariano Castelli, Guillermo Pfund, Ignacio de Luca, Darío Chikiar,
Mariano Castelli, Paula Socias, Juan Padilla, Patricio Zaefferer.
Instituto Cardiovascular de Buenos Aires.

The narrowing of the aorta known as coarctation (CoA) is a common congenital malformation diagnosed and corrected during infancy in most cases. Those patients that had been surgically corrected, may develop false aneurysms (FA) at the repair site related to all methods of surgical correction. The endovascular procedure was proposed by several authors for the treatment of adult FA, and for other complications developed many years after surgical reconstruction. We describe our experience with TEVAR in four patients.

Caso N°1: 35 year old male patient with history of type B aortic arch interruption corrected at age 5 with a 16 mm Dacron graft interposition; mechanical aortic valve and ascending aorta replacement with bilateral subclavian bypass due to a 49 mm rapidly increasing ascending aorta aneurysm with moderately insufficient bicuspid aortic valve at age 29, that required reoperation for bleeding and for which he is currently under oral anticoagulation. He developed a 60 mm descending thoracic false aneurysm at the distal anastomosis of the Dacron interposition graft (Figure 1A). A two-staged hybrid repair was attempted at another institution; first a right to left carotid-carotid bypass with proximal left carotid occlusion was made and then, TEVAR exclusion of the false aneurysm was attempted but failed due to technical issues. After interdisciplinary approach at our institution, we decided to attempt endovascular repair, even though there was a prior failed attempt, as a third re-do operation would have been technically demanding and risky. Under general anaesthesia through surgical right femoral access a Zenith TX 2 (Cook Medical, Bloomington, IN) was deployed into the descending aorta excluding the false aneurysm. As a type IB endoleak was seen in the intraoperative angiogram, an XXL Andrastent ballon expandable stent (Andramed, Reutlingen, DE) was deployed to achieve an adequate distal seal. 1-month CT angiography shows patent graft with a retrograde type II endoleak coming from both native subclavian arteries. The endoleak was addressed with endovascular treatment. Under general anaesthesia through percutaneous bilateral radial access both native subclavian arteries were plugged with a 14 mm Amplatzer Vascular Plug II (AGA Medical Corp, Plymouth, MN) and the false aneurysm coiled with three 20 mm Azur Framing coils (Terumo, Somerset, NJ) Postoperative CT angiography shows a recurrent type II endoleak from the left subclavian artery with right sublclavian artery occluded.

Figure 1: A :Preoperative CT reconstruction. B- 1 month follow up CT scan after the first procedure shows type II endoleak from both subclavian arteries. C: CT scan after second procedure shows persistent type II endoleak from the left subclavian with right subclavian occlusion.

Case N°2: 34 year old female patient with history of chlidhood aortic coarctation repaired at age 3 with open patch aortoplasty who presents in a routine follow-up exam with an asymptomatic 60 mm false aneurysm of the aortic patch involving the origin of the left subclavian artery (zone 2). The patient was treated with a two-stage procedure; first a left carotid-subclavian ePTFE bypass graft was made and then the pseudoaneurysm was excluded by deploying a 26 mm thoracic endograft and a left subclavian plug.

Figure 2-A: CT-angiography showing a 60 mm descending thoracic aorta false aneurysm involving the origin of the left subclavian artery. Innominate and left carotid arteries are not affected.

Figure 2-B: 5-year CT angiography shows complete exclusion of the false aneurysm with patent graft and sac shrinkage.

Case N°3: 38 year old male patient who was surgically treated when he was 2 y-o for aortic coarctation with a left subclavian artery patch, having an uneventful recovery.At age 28, he was studied because of arterial hypertension. A thoracic false aneurysm was suspected in a chest Xray and was confirmed with a CT Scan. The 70 mm false aneurysm originated immediately distal to a re-stenosis of the previously repaired coarctation. Having no space of healthy aorta distal to the left carotid artery, a right to left carotid-carotid by-pass with proximal left carotid ligation was performed prior to the endovascular treatment. A week later the endovascular procedure was done successfully, using two Relay Plus (Bolton Medical, Barcelona, ES) stent-grafts (24 X 145 mm and 28 X 145mm) to exclude the false aneurysm and after that, once the re-coarctated aorta was protected by the endograft, 16, 20 and 22 mm balloon angioplasty was performed in order to dilate it. The patient was lost to follow for 8 years until he came back last year. He was asymptomatic and a CT Scan was performed (fig 3). The false aneurysm is still completely excluded, the sac shrunk and both the carotid to carotid by-pass and left carotid artery are occluded.

Figure 3-A: Intraoperative angiogram.

Figure 3-B: 8 years Control CT scan, the false aneurysm excluded.

Caso N°4: 55-year-old hypertensive female with history of aortic coarctation from the transdiafragmatic aorta (T9) up to the level of the take-off of the superior mesenteric artery (L1) repaired at age 15 with an aortic 20-mm Dacron bypass graft (from T9 to L1). Twenty-one years later, she developed a false aneurysm at the distal anastomosis (L1, zone V1) successfully treated with another aorto-aortic bypass from the prior graft to the native aorta. Both renal arteries were reimplanted to the second graft. In regular follow up visit, a Contrast enhanced magnetic resonance imaging and three-dimensional reconstruction computed tomography scan showed a 7 cm diameter pseudoaneurysm (1) at the proximal anastomosis (located at T9, zone V3; 7 cm above the celiac trunk and 14 cm below the left subclavian artery, figure). Distal anastomosis and visceral arteries appeared intact. Due to the patient’s prior surgical history and to high risk of visceral and spinal cord ischemia, open repair was deemed challenging and risky, so a decision was made to perform an hybrid approach with open cut-down access to the bypass and abdominal aorta and endovascular grafting of the pseudoaneurysm. Under general anesthesia, a median laparotomy was performed, identifying the bypass graft and diaphragmatic abdominal aortic stump. An 8-mm Dacron polyester graft was sutured to the bypass in an end-to-side fashion as a working channel to enhance prosthesis handling. Access to the abdominal aortic stump (above celiac trunk) was gained through a 9F introducer sheath and a pigtail catheter was progressed over a 0,035 inch guide wire into the aortic arch to perform diagnostic angiograms. An aorto-aortic graft-to-native aorta stump crossover maneuver was made to deploy the contralateral limb. Through the working channel, a 10 F sheath was inserted and a Lunderquist Extra Stiff wire (Cook Inc., Bloomington, IN) was advanced into the ascending aorta and the sheath was withdrawn. Subsequently, a 28x16x140 mm Powerlink unibody bifurcated aortic endograft (Endologix, Irvine, CA) was delivered to the descending thoracic aorta. The ipsilateral limb of the graft was placed into the bypass graft covering the false aneurysm, whereas the contralateral limb was opened in the abdominal aorta, above the celiac trunk. An angiogram revealed an ipsilateral limb type IB endoleak into the seudoaneurysm. This resolved after deployment of a 20 x 25 x 65 mm distal extension cuff (Endologix, Irvine, CA) at the edge of the ipsilateral limb and low-pressure dilatation with an Amplatzer II 34 mm sizing balloon (AGA Medical). Completion angiogram showed total exclusion of the seudoaneurysm with normal flow through the bypass and celiac and superior mesenteric arteries patency. The patient was transferred to intensive care unit postoperatively, where recovery was satisfactory with no complication. Patient was discharged at postoperative day five. At 3 years postoperative imaging, complete exclusion of the pseudoaneurysm was confirmed by computed tomography angiography.

Figure 4: A: Preoperative 3D CT scan reconstruction showing the false aneurysm. B: 3 years follow up CT scan 3D reconstruction showing false aneurysm exclusion.

CoA is the congenital narrowing of part of the aorta distal to the left subclavian artery, with an incidence of 0.3-0.4/1000 live births. Narrowing of the isthmus around the insertion of the arterial duct is the most common site of obstruction and leads to thoracic CoA (1). The surgical treatment of coarctation with patch aortoplasty or angioplasty without stent presents high incidence of late complications like pseudoaneurysm (1, 2). Even with initial success, up to 9% of patients develop this lesion long after the procedure (2). According to Knyshov et al, conservative treatment of psuedoaneurysm after CoA surgical repair is unpredictable in short and medium follow-up, with 100% of rupture within 15 years (3). Open surgery after previous patch aortoplasty carries a 14% incidence of mortality or laryngeal nerve lesion and bleeding complications (4,5).

Different authors demonstrated that the use of stent-grafts for pseudoaneurysm post CoA is safe and effective (1,4,5). In our cases we used three different stentgrafts, Relay Plus, Zentih TX2, and in one special case an abdominal bifurcated stent-graft, Powerlink.

Ince et. al. (4) in a series of six patients, described the occlusion of left subclavian artery in three cases without revascularization, and reported no complications. We needed to occlude the subclavian artery in two patients. In another case, the left carotid artery was also occluded to extend the proximal landing zone into healthy aorta. In all cases, target arteries were revascularized with carotid-subclavian or carotid-carotid by-pass with no complications.

False aneurysms developing in adults after a prior CoA surgical correction during childhood can be treated safely with endovascular therapy. Nevertheless, long-term results still have to be expected.

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