This article has Open Peer Review reports available.
Endovascular repair of an aortic arch pseudoaneurysm with double chimney stent grafts: a case report
© Zhou et al.; licensee BioMed Central Ltd. 2013
Received: 22 January 2013
Accepted: 8 April 2013
Published: 11 April 2013
Aortic arch pseudoaneurysm is a rare condition but carries a high risk of rupture. We report a case of a 45-year-old man with aortic arch pseudoaneurysm between left common carotid artery (LCCA) and left subclavian artery (LSA), in which a endovascular stent graft combined with double chimneys covered stents were successfully placed. There were no any complaints and complications after 12 months follow-up. The CTA demonstrated thrombus formation in the pseudoaneurysm lumen, no endoleak and the aortic arch, LCCA and LSA were all patent. We feel that the combined endovascular and double chimneys may be a valuable therapeutic alternative when treating aortic arch lesion. However, long-term clinical efficacy and safety have yet to be confirmed.
Aortic arch pseudoaneurysm is a rare condition but carries a high risk of rupture. Previous reports that we have identified in English literature included conventional surgical repair, hybrid surgery,embolization of an aortic arch pseudoaneurysm with detachable coils and total endovascular debranching of the aortic arch or double-chimney technique [1–7]. Conventional surgical intervention requires a thoracotomy, cardiopulmonary bypass, hypothermic circulatory arrest and aortic cross-clamping, remains a surgical challenge with a high rate of mortality (7-17%) and neurologic complication (4-12%) [1, 2, 8]. Minimally invasive endovascular repair in treating aortic arch pseudoaneurysm is a better choice. We present a case of aortic arch pseudoaneurysm between left common carotid artery (LCCA) and left subclavian artery (LSA), in which a endovascular stent graft combined with double chimneys covered stents were successfully placed. As we know, there was seldom reported in English literature.
Reported treatment options for aortic arch pseudoaneurysms have included surgical grafts, ligation, pericardial roll graft replacement, embolization with coils, and the use of endovascular stent grafts combined with surgical treatment [1–7, 9]. The conventional open surgery was gradually replaced by endovascular treatment due to the complexity of the surgery, surgical trauma and high associated mortality rate. Endovascular treatment is less invasive and is associated with lower morbidity and mortality [3–5]. Since endovascular procedure does not require thoracotomy, circulatory assistance is not necessary and haemorrhages are less likely. What is more, endovascular intervention does not need aortic cross-clamping as such the risk of cerebral, spinal cord and visceral ischemia was decreased. Due to the lower morbidity and mortality rates, thoracic endovascular aortic repair (TEVAR) is considered an acceptable alternative to open surgical repair for patients with various types of aortic diseases. Despite these advantages, TEVAR are technical challenging. The common problem is the presence of an inadequate short proximal and distal landing zone. To achieve an adequate landing zone and sealing zone, the innominate artery, LCCA and LSA need occasionally to be covered. Modification of the stent graft is needed to overcome these limitations of TEVAR. The use of a fenestrated or branched stent graft, which is able to preserve perfusion of the supra-aortic arch vessels, could be one of the alternative approaches . However, a fenestrated or branched stent graft is a custom made device, and is expensive and time consuming to manufacture so they cannot be used in an emergency setting [11, 12]. In our patient, coil embolization and endovascular injection of embolic agents were not options because of the caliber of the aorta arch pseudoaneurysm tear (15 mm) and the size of pseudoaneurysm lumen (50 mm). The optimal option for treatment would be TEVAR. However, simple application of TEVAR to treat complicated aortic arch pseudoaneurysm such as in our patient may cause cerebral ischemia and infarction because of the limited landing zone and sealing zone. An alternative approach to this situation is applying the “chimney graft” technique to preserve blood flow to the supra-aortic arch vessels with a short landing zone, that would be impossible to repair with a standard stent graft . The chimney graft is defined as a bare or covered stent that is placed parallel to the main stent graft to preserve blood flow to the supra-aortic arch vessel, which is covered to achieve the proper landing and sealing zone . Since the procedure was introduced, the chimney graft has been successfully applied to preserve the blood flow of the carotid, subclavian, renal and superior mesenteric arteries during endovascular treatment of aortic disease [15–17]. LCCA and LSA covered stents implantation (double chimneys) would be protective of cerebral ischemia or cerebral infarction and subclavian artery steal syndrome. Our successful treatment in this patient suggests that the combined endovascular and double chimneys may be a valuable therapeutic alternative when treating aortic arch lesion, in order to perform a less aggressive surgery and avoid aortic cross-clamping, circulatory assistance and high dose heparinization. Long-term follow-up of a larger number of patients is needed to assess and confirm this favorite result in order to promote this approach. Branched and fenestrated aortic stent graft may be the next approach when it is more convenient, less complicated and available as an off-the-shelf device .
Although early results are promising, long-term clinical efficacy and safety have yet to be confirmed.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors thank Tom kuang, MD for retouching the manuscript.
- Harrington DK, Walker AS, Kaukuntla H: Selective antegrade cerebral perfusion attenuates brain metabolic deficit in aortic arch surgery: a prospective randomized trial. Circulation. 2004, 110 (11 Suppl1): II231-II236.PubMedGoogle Scholar
- Lee HL, Liu KH, Yang YJ: Bacteroides fragilis aortic arch pseudoaneurysm: case report with review. J Cardiothorac Surg. 2008, 3: 29-32. 10.1186/1749-8090-3-29.View ArticlePubMedPubMed CentralGoogle Scholar
- Marana MAI, Alonso VG, Revuelta NC: Combined treatment, endovascular and surgical treatment of posttraumatic pseudoaneurysm in the aortic arch. EJVES Extra. 2006, 12 (9): 25-29.View ArticleGoogle Scholar
- Choi BK, Lee HC, Lee HW: Successful treatment of a ruptured aortic arch aneurysm using a hybrid procedure. Korean Circ J. 2011, 41: 469-473. 10.4070/kcj.2011.41.8.469.View ArticlePubMedPubMed CentralGoogle Scholar
- Sanchez MJ, Ananian CL, Berkmen T: Embolization of an aortic arch pseudoaneurysm with coils and N-Butyl-Cyanoacrylate. J Vasc Interv Radiol. 2006, 17: 1677-1679. 10.1097/01.RVI.0000240739.17833.60.View ArticlePubMedGoogle Scholar
- Yoshida RA, Kolvenbach R, Yoshida WB: Total endovascular debranching of the aortic arch. Eur J Vasc Endovasc Surg. 2011, 42 (5): 627-630. 10.1016/j.ejvs.2011.06.054.View ArticlePubMedGoogle Scholar
- Shahverdyan R, Gawenda M, Brunkwall J: Triple-barrel graft as a novel strategy to preserve supra-aortic branches in arch-TEVAR procedures: clinical study and systematic review. Eur J Vasc Endovasc Surg. 2013, 45 (1): 28-35. 10.1016/j.ejvs.2012.09.023.View ArticlePubMedGoogle Scholar
- Westaby S, Katsumata T, Vaccari G: Arch and descending aortic aneurysms: influence of perfusion technique on neurological outcome. Eur J Cardiothorac Surg. 1999, 15: 180-185. 10.1016/S1010-7940(98)00310-8.View ArticlePubMedGoogle Scholar
- Kubota H, Endo H, Noma M: Equine pericardial roll graft replacement of infected pseudoaneurysm of the aortic arch. J Cardiothorac Surg. 2012, 7: 45-49. 10.1186/1749-8090-7-45.View ArticlePubMedPubMed CentralGoogle Scholar
- Malina M, Resch T, Sonesson B: EVAR and complex anatomy: an update on fenestrated and branched stent grafts. Scand J Surg. 2008, 97: 195-204.PubMedGoogle Scholar
- Chuter TA, Schneider DB: Endovascular repair of the aortic arch. Perspect Vasc Surg Endovasc Ther. 2007, 19: 188-192. 10.1177/1531003507304165.View ArticlePubMedGoogle Scholar
- Sonesson B, Resch T, Allers M: Endovascular total aortic arch replacement by in situ stent graft fenestration technique. J Vasc Surg. 2009, 49: 1589-1591. 10.1016/j.jvs.2009.02.007.View ArticlePubMedGoogle Scholar
- Criado FJ: Chimney grafts and bare stents: aortic branch preservation revisited. J Endovasc Ther. 2007, 14: 823-824. 10.1583/07-2247.1.View ArticlePubMedGoogle Scholar
- Lee KN, Lee HC, Park JS: The modified chimney technique with a thoracic aortic stent graft to preserve the blood flow of the left common carotid artery for treating descending thoracic aortic aneurysm and dissection. Korean Circ J. 2012, 42: 360-365. 10.4070/kcj.2012.42.5.360.View ArticlePubMedPubMed CentralGoogle Scholar
- Greenberg RK, Clair D, Srivastava S: Should patients with challenging anatomy be offered endovascular aneurysm repair?. J Vasc Surg. 2003, 38: 990-996. 10.1016/S0741-5214(03)00896-6.View ArticlePubMedGoogle Scholar
- Allaqaband S, Jan MF, Bajwa T: “The chimney graft”-a simple technique for endovascular repair of complex juxtarenal abdominal aortic aneurysms in no-option patients. Catheter Cardiovasc Interv. 2010, 75: 1111-1115.PubMedGoogle Scholar
- Donas KP, Pecoraro F, Bisdas T: CT angiography at 24 months demonstrates durability of EVAR with the use of chimney grafts for pararenal aortic pathologies. J Endovasc Ther. 2013, 20 (1): 1-6. 10.1583/12-4029.1.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.