Endovascular repair of a penetrating thoracic aortic ulcer by way of the carotid artery

INTRODUCTION: Endovascular repair of thoracic aortic lesions offers an attractive alternative to traditional open repair. Access to the thoracic aorta can occasionally be challenging because of large device size and vessel tortuosity. Traditional access by way of the femoroiliac vessels might not be possible in the setting of synchronous iliac occlusive disease. MATERIALS AND METHODS: A 63-year-old woman presented with a 7.1-cm symptomatic, penetrating ulcer of the descending thoracic aorta. The patient's severe pulmonary disease prohibited an open repair. A Talent endoprosthesis was placed under compassionate use with approval of the institutional review board. The graft was placed by way of the left common carotid artery because of severe iliac occlusive disease. RESULTS: The thoracic endograft was successfully placed with exclusion of the pseudoaneurysm. The patient's chest pain resolved immediately. She developed mild left-sided weakness from a postoperative right anterior cerebral artery stroke that quickly resolved. The patient was discharged on postoperative day 5. No aortic endoleak was noted on follow-up computerized tomography scan at 1 month. CONCLUSIONS: Endovascular repair should be considered in patients with thoracic aortic aneurysms, particularly those with severe medical comorbidities. Placement by way of the common carotid artery is technically feasible in the setting of synchronous aortoiliac disease.     

Endovascular stent-graft repair of penetrating descending thoracic aortic ulcer

This article presents a case in which covered stent-graft cuffs were used to treat a penetrating ulcer of the descending thoracic aorta. An 80-year-old woman presented with penetrating ulcer in the descending thoracic aorta. Two endovascular stent graft cuffs were used for total exclusion of the penetrating ulcer, because the patient had a high operative risk. Her postoperative course was uneventful, and follow-up computed tomographic angiography showed complete coverage of the ulcer without evidence of leak. This case demonstrates that endoluminal stent-graft repair of penetrating descending thoracic aortic ulcers is a safe, less-invasive treatment, especially for elderly, high-risk patients.     

Hybrid aortic arch repair for a ruptured and infected penetrating atherosclerotic ulcer of the aortic arch

Aortic arch rupture is a life-threatening emergency. Conventional open surgical repair carries a high mortality and morbidity. We report a case of an elderly patient who suffered from a ruptured and infected penetrating ulcer of the aortic arch. A hybrid operation was performed, consisting of a right-to-left carotid bypass and transposition of the left subclavian artery into the left common carotid artery followed by endovascular repair of the aortic arch. Antibiotic therapy, based on the results of culture and sensitivity tests for Staphylococcus aureus, was administered for 6 months. The patient recovered uneventfully and remains asymptomatic 16 months after the procedure. However, long-term follow-up is mandatory to determine the efficacy and the durability of this technique.     

Endovascular repair of a penetrating thoracic aortic ulcer presenting with left recurrent laryngeal nerve palsy

Endovascular repair offers minimally invasive management of otherwise complex thoracic aneurysms. Here, a case is reported of a 74-year-old man, a known hypertensive and ex-smoker, who underwent fiberoptic bronchoscopy for gradually progressing intermittent hoarseness of voice, which revealed incomplete left vocal cord palsy with no visible mass; however, computerized tomography and subsequent arteriography demonstrated a penetrating thoracic aortic ulcer with an associated false aneurysm (5 x 4 cm) from the distal inferior aortic arch just beyond the left subclavian origin, possibly compressing the left recurrent laryngeal nerve. Successful repair of the pseudoaneurysm was undertaken by endovascular technique with marked resolution of hoarseness after 1 year of follow-up.     

Endovascular repair of the ruptured abdominal aortic aneurysm.

The present knowledge on endovascular repair of ruptured abdominal aortic aneurysms (rAAA) prevents firm conclusions when to use this method in comparison to open repair. This review article briefly summarizes results from case series, and discusses how to achieve reliable information despite the absence of randomized controlled trials. At present a careful conclusion might be that dedicated centers with an adequate organization and reasonably high volume of abdominal aortic aneurysm (AAA) should use detailed registry protocols to achieve experience and data to create an as reliable basis as possible for future recommendations.     

Endovascular repair for ruptured thoracic aortic aneurysm and traumatic aortic injury

In contrast to high mortality of open surgery for thoracic aortic catastrophes including ruptured thoracic aortic aneurysm (RTAA) and traumatic aortic injury (TAI), excellent short-term outcomes of thoracic endovascular aortic repair (TEVAR) have recently been reported. We report our single-center experiences with TEVAR for aortic catastrophes. Thirteen patients with thoracic aortic catastrophes (RTAA in 7 patients, TAI in 6 patients) have received TEVAR from February 2004 to June 2010. In cases of RTAA, 5 descending aortic aneurysm ruptures and 2 aortic arch aneurysm ruptures were included. In patients with arch aneurysm ruptures, fenestrated stent grafting (SG) and SG combined with arch debranching were performed. In all cases of TAI, aortic injuries occurred near the isthmus and 5 patients received fenestrated SG. The initial success rate was 100% and there was no perioperative death. Mean duration of observation was 24 months, which revealed 4 late deaths. The causes of late death were liver failure, cerebral contusion, senility and unknown. A patient with RTAA experienced a type III endoleak as an aorta-related event 24 months after operation. There was no enlargement of aneurysm in any patient. TEVAR for aortic catastrophes seems to be performed safely with acceptable outcomes. Although morphological incompatibility, unstable preoperative haemodynamics and longer time for preparation may become impediments to perform TEVAR, we believe that TEVAR should be the 1st choice for life-threatening aortic catastrophes. However, a careful follow-up is necessary because TEVAR has several unique late complications.     

Endovascular repair of a ruptured giant popliteal artery aneurysm

An 88-year-old woman with hypertension, chronic vein insufficiency, and repeated cellulites in the right lower extremity was admitted to our hospital with a new episode of right leg inflammation and edema associated with fever and leukocytosis. Due to unilateral enlargement of the leg and D-simer levels of 1000 microg/mL, a concomitant deep venous thrombosis was suspected and ultrasonography was performed. Color duplex-scanning found normal flow in the right deep leg veins but revealed an 11-cm-diameter popliteal artery aneurysm. A computed tomography scan confirmed the diagnosis and revealed a large perianeurysmal hematoma, and angiography provided evidence of perianeurysmal bleeding. The patient was unfit for open surgery, so an endovascular approach under local anesthesia was elected. The aneurysm was successfully excluded with an endograft, and 15 months after surgery, the patient is alive and had an uneventful postoperative course.     

Endovascular repair of a ruptured chronic type B aortic dissection

Aneurysm formation is a common sequel of chronic type B aortic dissection. Ruptured false lumen aneurysms have traditionally been treated with open repair. These procedures are associated with high morbidity and mortality rates. We report the first successful endovascular repair of a ruptured chronic type B aortic dissection in a patient who had been turned down for elective surgery. The endovascular management of chronic dissection with rupture is difficult and may necessitate stenting of both entry and reentry points to induce false channel thrombosis. The long-term efficacy of this technique is unknown.     

腹主动脉瘤破裂行腔内修复术1例

患者女,80岁,因急性脑梗死伴腹痛9h入院。查体:下腹部左侧触及6～7cm搏动性包块,右侧中枢性面瘫,右上肢肌力0级,疼痛刺激无反应,右下肢外旋,可屈曲,无自主运动;左侧肢体肌力Ⅳ级,左侧Babinski征阳性,右侧病理征未引出。既往有糖尿病、高血压及腹主动脉瘤病史。     

腔内覆膜支架植入术治疗穿透性硬化性主动脉溃疡

穿透性粥样硬化性主动脉溃疡（penetratingath-eroscleroticaorticulcer,PAU）指主动脉内膜粥样硬化斑块形成后,在其表面破溃形成溃疡,穿透动脉壁中膜乃至外膜;临床上与主动脉夹层动脉瘤、主动脉壁内血肿等均可表现为急性主动脉综合征。PAU破裂的危险明显高于主动脉夹层,在急诊病例中约409／6患者死亡。本研究采用血管内覆膜支架植入术治疗PAU,效果良好,现报道如下。     

Endovascular repair of an infected carotid artery pseudoaneurysm

Pseudoaneurysm formation after carotid endarterectomy is a rare but potentially lethal complication. The risks for embolization and continued expansion necessitate repair. Traditional surgical repair of carotid pseudoaneurysms is often technically demanding, and is associated with relatively high morbidity and mortality. Endovascular stent grafts have been used to treat both posttraumatic and postoperative carotid pseudoaneurysms. An endovascular approach to these pseudoaneurysms limits the risks for operative damage to surrounding structures and the potential for substantial blood loss. We present the case of an infected carotid pseudoaneurysm that was successfully treated with a covered stent graft.     

症状性主动脉穿透性溃疡的腔内修复术

目的 探讨症状性主动脉穿透性溃疡（penetrating atherosclerotic ulcer,PAU）的临床诊断和支架型人工血管腔内修复术的临床价值。方法 回顾分析2004年9月至2010年4月治疗的12例症状性PAU患者的临床资料,所有患者均有突发胸背部疼痛等急性主动脉综合征的临床表现,计算机断层扫描血管成像（computer tomography angiography,CTA）确诊为Stanford B型PAU,其中8例合并主动脉壁间血肿,所有患者均在全麻下接受支架型人工血管腔内修复术,两例附加杂交旁路手术延长近远侧锚定区。本组12例中10例患者获得随访,随访率83.3％。随访时间1～4年（中位时间36个月）,随访率83.3％ (10/12)。结果 12例患者共植入支架型人工血管12枚,其中植入支架直径32～40 mm,平均(35.7 ±2.5) mm,长度152 ～ 202 mm,平均(163±19) mm。1例溃疡较大病例支架人工血管植入后存在极少量内漏外,其他溃疡均隔绝满意。技术成功率100％。围手术期无不良事件发生。随访中患者无症状复发及死亡。CTA检查结果满意无内漏,1例少量内漏患者术后3个月复查内漏消失。结论 支架型人工血管腔内修复术因其微创、有效可能成为现阶段症状性PAU的首选治疗手段,术后严格的血压控制是长期疗效的有效保证。     

Endovascular repair of symptomatic external carotid artery stenosis

The treatment of external carotid artery stenosis has been described with a variety of operative interventions. We present a patient who presented with amaurosis fugax and a critical left external carotid artery stenosis with known left internal carotid artery occlusion. We treated this stenosis with angioplasty and stenting rather than endarterectomy. Our patient did well and had no complications from the procedure. Endovascular repair of symptomatic external carotid artery stenosis provides an alternative treatment method to conventional endarterectomy for patients with high surgical risk.     

Endovascular repair of ruptured abdominal aortic aneurysms: systematic literature review

Endovascular repair is increasingly used for ruptured abdominal aortic aneurysms (RAAAs). This study estimated the mortality rate for this approach. A review of 307 publications in English was performed. Thirty-four publications representing 1,200 patients with RAAA were deemed appropriate for analysis by weighted least squares regression. Of the 1,200 patients, 531 (44.3%) underwent endovascular aneurysm repair (EVAR). The average age was 74 years, and 13% were female. Aortouni-iliac grafts were used in 49.4% of patients, and 50.6% received bifurcated grafts. The technical success rate was 94.9%, with a mortality rate of 30.2%. The ratio of endovascular cases to the total number of cases strongly predicted the mortality rate (weighted coefficient -0.378, p< .0003). The mortality rate following EVAR of RAAA is 30%. A 3.8% reduction in mortality was found for each 10% increase in the percentage of ruptures repaired endovascularly at each center. These results are suggestive of a learning curve.     

Endovascular repair of symptomatic penetrating atherosclerotic ulcer of the thoracic aorta.

BACKGROUND: In this study we evaluate published and personal experience of Endovascular Repair (EVAR) of penetrating atherosclerotic ulcers (PAU). PATIENTS AND METHOD: In 12 patients (mean 74 years, 58-87 years) PAU was diagnosed with computer tomography (CT). Symptomatic ulcers were treated by vascular surgeons using stentgrafts via a femoral access route. Patients were followed up clinically and with CT for an average of 849 days (186-1968 days). RESULTS: 11 patients had severe acute thoracic pain, one patient presented with hemoptysis. CT showed well outlined ulcer, intramural hematoma, and contrast enhancement of the aortic wall (n=12), pseudoaneurysm (n=11), intimal calcification adjoining the ulcer (n=10), pleural (n=9) and mediastinal fluid (n=4). Mean duration of surgery was 68min (32-120min). Primary technical success was achieved in all patients. There was no perioperative complications except one acute hemorrhage from an intercostal artery and one iliac dissection. 3 months after stentgraft application owing to a severe stenosis of the right common femoral artery, an iliofemoral bypass was performed in one patient. All patients were free of symptoms after the procedure. There was incomplete sealing of PAU in 2 of 12 patients, but no re-intervention was needed. All patients were alive during follow-up. CONCLUSION: Symptomatic PAU is a potentially fatal lesion. Considering the low morbidity and mortality of EVAR, this option might be first choice.