Failed surgical ligation of the proximal left subclavian artery during hybrid thoracic endovascular aortic repair successfully managed by percutaneous plug or coil occlusion: a report of 3 cases
© Maleux et al; licensee BioMed Central Ltd. 2011
Received: 17 December 2010
Accepted: 8 April 2011
Published: 8 April 2011
Open surgical rerouting and proximal ligation of one or more supra-aortic vessels prior to endovascular stent-graft placement has become an alternative to major open thoracic surgery in the treatment of complex thoracic aortic disease. Complications owing to failed surgical ligation of the left subclavian artery are rare. In this report, 3 cases of failed ligation are presented. Diagnosis was made by CT-scan and treatment was performed by transcatheter coil and plug embolization, avoiding redo neck surgery.
Endovascular repair has become a valuable alternative to open repair for the treatment of several thoracic aortic pathologies [1–4]. However, stent-graft placement requires an adequate proximal and distal landing zone in the aorta of at least 2 cm in order to avoid early or late type I endoleak. Therefore, surgical ligation and rerouting of one or more supra-aortic vessels can be necessary for safe stent-graft deployment and efficient and durable clinical outcome. Recent reports deal with the successful technical and clinical outcome after supra-aortic rerouting [5–7]. However, type and management of complications related to this type of open vascular surgery are scarce and not well-documented . In this report we present the clinical and radiological outcome after endovascular management of failed surgical ligation of the left subclavian artery during supra-aortic rerouting for safe thoracic stent-graft placement.
From 1999 to end of 2009, 172 thoracic stent-graft procedures in 160 patients were performed in the author's institution. In 49 patients (30%), supra-aortic rerouting was performed. In 41 out of these 49 patients (84%) perioperative surgical ligation of the left subclavian artery was performed in association with supra-aortic rerouting. All patients were followed up according to the EUROSTAR guidelines . In 3 out of these 41 patients (7%) previously treated by left subclavian artery ligation, persistent flow through the ligated artery was identified and associated with gradual increase of aneurismal or false luminal diameter. There were no patients with persistent retrograde flow through the prevertebral left subclavian artery, but with a stable or decreasing aneurismal sac.
A 78-year-old man presented with an asymptomatic aneurysm of the proximal descending thoracic aorta with a maximal diameter of 66 mm. The patient already underwent endovascular exclusion of an abdominal aortic aneurysm two years earlier. It was decided to exclude the thoracic aneurysm with use of a stent-graft (Valiant, Medtronic, Santa Clara, CA, USA) after placing a carotidosubclavian bypass and ligation of the proximal left subclavian artery in order to minimize potential postoperative neurological symptoms related to myelum ischemia. The postoperative period was uneventful except for fever up to 38°C for 3 days; no signs of arm claudication were noted. Control CT-scan 6 months later revealed discrete increase of the aneurismal sac diameter up to 69 mm owing to a type II endoleak by retrograde sac perfusion through the incompletely ligated proximal left subclavian artery. It was decided to treat the endoleak. Under local anesthesia, the left brachial artery was punctured and a 45 cm long 8 F sheath (Arrows, Reading, PE, USA) was inserted. Angiography revealed the retrograde opacification of the prevertebral segment of the left subclavian artery, resulting in a type II endoleak. A 16 mm nominal diameter vascular plug (Amplatzer vascular plug, AGA Medical, Plymouth, MN, USA) was placed at the origin of the left subclavian artery, with complete disappearence of the endoleak. Control CT-scan at one and two years follow-up revealed absence of any residual type II endoleak and stable diameter of the thoracic aneurysm up to 68 mm.
Combined open and endovascular surgical repair is recently propagated as a less invasive treatment option for the management of aortic arch pathologies like aneurysms, dissections or penetrating ulcers [1, 7, 9–12]. However, these operations are also not free of early or late complications: myocardial infarction, respiratory and renal failure, postoperative hematoma, vertebrobasilar insufficiency or stroke are potential complications [13–18]. In this study we report on a yet unreported, not very uncommon (7% of all supraaortic rerouting cases with ligation), but silent complication after supra-aortic rerouting, namely an incomplete ligation of the left subclavian artery resulting in persistent perfusion of the thoracic aneurysm in two cases and in persistent, retrograde perfusion of the false lumen in the remaining case. Additionally, in all cases these radiological findings were associated with a gradual growth of the aneurismal sac or false lumen, stressing the importance of this silent complication. Adequate treatment seems to be mandatory to avoid potential late rupture. In the presented cases, a surgical attempt was made to ligate the prevertebral segment of the left subclavian artery; however, owing to surgical difficulties to clearly visualize and manipulate the deeply located proximal left subclavian artery, the ligation was incomplete in two cases and impossible in the remaining case. It is also understandable that a redo operation in these cases is even more hazardous and by consequence, a minimally invasive alternative treatment is preferred. Persistent flow through the left subclavian artery was identified in all three cases by contrast-enhanced CT-scan, underlining the value of regular follow-up CT-scan after endovascular repair of aortic pathologies. In all three cases the proximal left subclavian artery was approached by puncture of the left brachial artery; the decision to occlude with coils [19–21] or plug [13, 22–25] depended on the diameter of the prevertebral subclavian artery segment: if the segment was large enough for a plug (n = 2), then a plug was preferred owing to the ease of plug deployment; in the remaining case the prevertebral segment was too small for safe plug-deployment and microcoils were placed through a microcatheter. Except for a puncture site hematoma, no complications occurred during or after the procedure and in all cases no more perfusion of the occluded vessel was indentified on sequential follow-up CT-scan. The endovascular occlusion of the proximal left subclavian artery has been successfully performed in cases of intentional left subclavian artery coverage by the endograft, without previous carotid-subclavian transposition [13, 19, 20, 22–25], using the same endovascular techniques. Finally, the gradual growth of the aneurismal sac or false lumen was stopped after the occlusion procedure.
In summary, three cases of persistent flow through the left subclavian artery after combined open en endovascular surgery for thoracic aortic disease are presented. CT-scan clearly identified the persistent left subclavian artery opacification, despite previous surgical attempt of ligation; catheter-angiography confirmed these findings. Definitive occlusion of the prevertebral part of the left subclavian artery can be performed using plug or coils, resulting in disappearance of the endoleak and in cessation of the aneurismal or false lumen growth.
In our institution no approval of the Ethical Committee is required for case reports.
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