Download Abou Al-Shaar H et al. 1 Title: Hybrid Repair of Thoracoabdominal

Abou Al-Shaar H et al. 1
Title:
Hybrid Repair of Thoracoabdominal Aortic Aneurysm with Thrombosed Infrarenal Aortic Aneurysm without Aortic
Clamping: A Modified Technique.
:‫اإلصالح الهجين لتمدد االشريان األبهري الصدري البطني المصحوب بتخثر الشريان األورطي أسفل الشريان الكلوي من دون اغالق الشريان االبهري‬
.‫تقنية مستحدثة‬
Abstract
We report the successful repair of a Crawford type III thoracoabdominal aortic aneurysm (TAAA) with thrombosed
infrarenal component using a modified hybrid technique without aortic clamping in a high-risk patient. A 64-yearold male with known case of hypertension, diabetes, and severe COPD was referred to our service due to an
enlarging Crawford type III TAAA, with chronic thrombosis of the infrarenal component of the TAAA and both
common iliac arteries. The patient complained of severe leg claudication and chronic back pain. A single-stage
modified hybrid procedure involving an aortobifemoral bypass without aortic clamping, debranching of right renal,
superior mesenteric and celiac arteries, and an endovascular repair of the thoracic aneurysm were performed. TAAA
with thrombosed infrarenal aorta and bilateral common iliac arteries can be repaired using a single-stage modified
hybrid procedure without aortic clamping in high-risk patients who cannot tolerate thoracotomy and aortic clamping.
‫نبلغ هنا عن حالة إصالح ناجحة لتمدد الشريان األبهري الصدري البطني (كروفورد ثالثة) المصحوب بتخثر الجزء األسفل كلوي باستخدام تقنية‬
‫ عاما وهو مصاب بارتفاع ضغط الدم ومرض‬64 ‫ المريض يبلغ من العمر‬.‫الهجين المستحدثة من دون اإلغالق المؤقت للشريان االبهري البطني‬
‫السك ري ومرض االنسداد الرئوي المزمن الشديد والذي شخص بتمدد الشريان األبهري الصدري البطني (كروفورد ثالثة) مصحوبا بتخثر الجزء األسفل‬
‫ أجرينا على المريض عملية الهجين‬.‫ اشتكى المريض من عرج شديد في كال الساقين وآالم الظهر المزمنة‬.‫كلوي وكال الشرايين الحرقفية المشتركة‬
‫ يمكن إصالح تمدد الشريان األبهري الصدري البطني‬.‫المستحدثة من دون اإلغالق المؤقت للشريان األبهري البطني ومن دون أي مضاعفات‬
‫المصحوب بتخثر الجزء األسفل كلوي باستخدام عملية الهجين المستحدثة في عملية واحدة ومن دون اإلغالق المؤقت للشريان االبهري البطني خصوصا‬
.‫عند المرضى ذو الخطورة العالية الذين ال يستطيعون تحمل العمليات الجراحية الصدرية‬
Key Words: Thoracoabdominal, Aortic, Aneurysm, Thrombosis, Hybrid, Endovascular.
Abou Al-Shaar H et al. 2
Introduction
Thoracoabdominal aortic aneurysms (TAAA) are associated with poor prognosis and high mortality rates if not
managed adequately, especially in high-risk patients. The management of TAAA itself carries an extensive risk of
perioperative morbidity and mortality to the patients [1-5]. For decades, open surgical repair was the modality of
choice for such aneurysms [1]. However, with the introduction of endovascular techniques and the utilization of
combined open and endovascular approaches, managing TAAA can be done with significantly less devastating
outcomes [1-4, 6]. Herein, we report the successful treatment of a large thoracoabdominal aortic aneurysm
extending from the midthoracic aorta to the aortic bifurcations (Crawford type III), with thrombosis of the infrarenal
aorta and both common iliac arteries by performing a single-stage modified hybrid procedure. In addition, we
describe our modified hybrid technique without aortic clamping and review the medical literature on TAAA
management.
Case Report
History & Investigations
A 64-year-old male with known case of hypertension, diabetes, and severe chronic obstructive pulmonary disease
(COPD) was referred to our department due to an enlarging Crawford type III TAAA extending from the
midthoracic aorta to the aortic bifurcations, with a thrombosed infrarenal aorta (Figure 1&2). He complained of
severe leg claudication and chronic back pain. The patient had a previous history of stroke with mild right
hemiparesis and slurred speech. He is epileptic but controlled on medications. Radiological investigations revealed a
left-sided pleural effusion on chest X-ray. Doppler ultrasound of the carotids showed intimal hyperplasia with few
calcified plaques in the right common carotid artery but no significant stenosis. Abdominal computed tomography
angiogram (CTA) revealed a large 6.5 cm thoracoabdominal non-ruptured aneurysm that was thrombosed below the
right renal artery, with occluded common iliac arteries. The celiac and right renal arteries were stenosed, but the
superior mesenteric artery was patent. The left renal artery was occluded with atrophied left kidney (Figure 1&2).
Creatinine levels were normal.
Technique
Open surgical repair of infrarenal portion of TAAA
Abou Al-Shaar H et al. 3
General anesthesia was induced and a spinal drainage was placed to keep the cerebrospinal fluid (CSF) pressure
below 10 mmHg throughout the procedure. A midline laparotomy was performed and the abdominal aortic
aneurysm (AAA) was exposed up to the renal arteries. A Full dose of heparin was given. 3 cm incision was made at
the anterior wall of the thrombosed AAA without aortic clamping and a bifurcated Dacron graft sized 20 x 10 mm
was anastomosed (end-to-side). Open thrombectomy of the thrombosed aneurysm was performed via one limb of
the graft to get access to the suprarenal aorta. A second bifurcated graft size 14 x 7 mm was placed in a reversed
position. End-to-side anastomosis was created between the main body of the graft and the previously placed
aortobifemoral bypass (ABFB) graft. The first limb of the graft was anastomosed to the right renal artery in an endto-side fashion. The second limb was sutured to the superior mesenteric artery (side-to-side) then passed behind the
pancreas and anastomosed to the celiac artery (end-to-side) (Figure 3). Left renal artery was not bypassed because it
was occluded with atrophic kidney.
Endovascular repair of thoracic portion of TAAA
Two tapered Medtronic, Inc. (Minneapolis, MN) stent grafts sized 28 x 24 x 15 mm and 36 x 32 x 15 mm were
deployed via the left limb of the ABFB graft extending from the mid thoracic aorta to the inside of the graft starting
from below upwards. Balloon angioplasty was then performed with subsequent ligation the origin of all debranched
vessels to prevent type II endoleak. The right and left limbs of the ABFB graft were then anastomosed (end-to-side)
to the right and left common femoral arteries respectively. A good pulse was then established in both common
femoral arteries and debranching bypass graft. Completion angiogram revealed complete exclusion of the TAAA
without any type of endoleak and good flow to all debranched arteries (Figure 4&5). The retroperitoneum was
closed covering all the grafts. Patient tolerated the procedure very well. He was hemodynamically stable during the
entire procedure and was transferred to the ICU in a stable condition with spinal drain in place.
Postoperatively
The patient was placed on prophylactic dose of heparin. CSF pressure was kept below 10 mmHg for 48 hours.
Patient was hemodynamically stable and off inotropic support. Neurological exam revealed no deficit. Kidney
functions deteriorated for 2 days then normalized. Because of his severe COPD, the patient was kept on a ventilator
for 4 days. On the fifth postoperative day and while we started weaning him off the ventilator, he suddenly started
Abou Al-Shaar H et al. 4
showing signs of progressive hypoxemia and became tachypnic. Clinical diagnosis of massive pulmonary embolism
(PE) was made and he was switched to IV heparin. Within less than one hour he became circulatory unstable with
signs of right heart failure. While we were preparing him for intervention to remove his massive PE, he suddenly
arrested. The patient could not be resuscitated.
Discussion
The management of TAAA is difficult and challenging. Open surgical repair as described by Crawford remained the
standard surgical technique for decades [1]. The introduction of endovascular approaches in the treatment of
descending aortic aneurysms by Dake et al. showed good outcomes providing an alternative to open surgical repairs
[7]. However, endovascular stenting was limited by the presence of renal and visceral arteries [1]. A combined
approach consisting of an endovascular exclusion of the aneurysm with open visceral and renal graft
revascularization was then first described by Quinones-Baldrich in the management of TAAA [8]. The technique is
based on retrograde graft revascularization of the visceral and renal arteries through laparotomy followed by
endovascular stenting of the aortic aneurysmal segment [2, 6].
The choice of a hybrid procedure over open surgical repair in the treatment of TAAA has shown major advantages,
due to the avoidance of thoracotomy, aortic cross clamping, hypothermia, single lung perfusion, visceral ischemia,
reperfusion injury, and extracoporal perfusion [1-4]. Thus, hybrid procedures have been associated with a shorter
postoperative recovery time, a decrease in blood loss by up to 60%, and a reduced stress response [3]. However, the
risk of paraplegia, spinal cord ischemia, hemorrhage, endoleak, respiratory and renal failure are all still of a concern
with this procedure [1, 2]. Paraplegia remains one of the most devastating and feared complications of hybrid
procedures but the risk is still much lower than open repair. The risk can be reduced by performing CSF drainage, as
reported by many authors [6, 9, 10]. Greenberg and Carroccio reported an increased risk of paraplegia associated
with an increased length of the graft [11-13].
Furthermore, the morbidity and mortality rates have been drastically reduced among patients undergoing hybrid
procedures. In a study of 1010 patients who underwent open surgical repair of TAAA, Rigberg et al. documented a
mortality rate of 19% and 31% in 30 days and one year, respectively [14]. A study by Black et al. demonstrated
morbidity and mortality rates after hybrid procedures to be 58% and 13%, respectively [4]. A review of 660 patients
who underwent hybrid procedures for the treatment of TAAA by Canaud et al., revealed a mean perioperative
Abou Al-Shaar H et al. 5
mortality rate of 12.6%. The mean rate of permanent spinal cord ischemia was also documented at 3.4%, mesenteric
ischemia at 4.6%, renal failure at 10.4%, severe cardiopulmonary complications at 7.8%, and endovascular leak at
18% [2]. The reported mean patency rate of 94.7% during a mean follow-up of 26.2 months by Canaud et al. was
similar to the results reported by Black et al. of 90-95% patency rates at 36 months follow-up time [2, 4]. We
believe these results encourage the use of hybrid procedures in the treatment of TAAA as a valid and feasible
alternative to open surgical repair.
Hybrid procedures in the treatment of TAAA were initially developed for managing patients with advanced age,
severe comorbidities, those unfit for extensive surgeries, and other high-risk patients [1, 2]. However, with
promising results in the reduction of morbidity and mortality, a number of authors recommend it in all TAAA
patients [4].
Advanced age (>60 years), cardiopulmonary comorbidities, previous cardiac surgeries, emergent surgeries, diabetes,
smoking, COPD, and renal insufficiency may all influence the outcome of hybrid procedures as reported by Böckler
and Rigberg [1, 14]. Our patient had multiple risk factors (diabetes, hypertension, and severe COPD). According to
Böckler et al. COPD is considered an independent risk factor for the overall survival of the patient with a significant
p value of 0.02 [1]. The death of our patient can be attributed to the presence of those multiple risk factors, as he was
transferred to the ICU in a stable condition and died 5 days after the operation from a massive pulmonary embolism
in spite of prophylactic dose of heparin.
Performing a hybrid procedure in a single-stage vs. two-stages remains controversial [2]. Some authors prefer the
two-staged procedure in order to decrease the complications associated with long operative durations (bleeding,
ischemia, iatrogenic injury, disseminated intravascular coagulation due to hypothermia, and respiratory failure due
to prolonged intubation), decrease contrast use, and ensure good spinal cord perfusion [1, 2, 6]. We, as well as other
authors, believe that the single-stage hybrid procedure reduces the risk of rupture during the interval time for the
second stage [4, 15]. However, according to a recent study, no clinically significant difference was detected between
the two approaches and their mortality rates [2].
The Chimney technique and branched/fenestrated endovascular stent grafting for TAAA have shown promising
results in many centers. Nonetheless, the medical literature lacks reported randomized clinical trials comparing them
to hybrid procedures in the treatment of TAAA. The fenestrated endovascular graft is custom made and puts highrisk patients in risk of TAAA rupture during the waiting time, limiting the value of such an approach. In our patient,
Abou Al-Shaar H et al. 6
none of these techniques, as well as the classical hybrid procedure, was feasible due to the anatomic limitation of
infrarenal aortic aneurysm and bilateral common iliac artery occlusion preventing endovascular stent access to the
suprarenal component of the aneurysm.
We believe that, even with the presence of infrarenal segment thrombosis of the TAAA, the use of our adjusted
hybrid technique is still safe and feasible. As described in our technique, the ABFB graft can be sutured to the
infrarenal aorta without aortic clamping, then, by performing a thrombectomy, adequate flow can be re-established
in the thrombosed site. In addition, the limbs of the ABFB graft can be utilized as potential new accesses to the
aortic aneurysmal segment for endovascular stenting and aneurysmal exclusion.
Conclusion
Hybrid repair of TAAA is considered a potential alternative to open surgical repair, especially in high-risk patients.
In the presence of an infrarenal thrombosis of the TAAA, a modified hybrid technique can be utilized by suturing an
ABFB graft to the anterior wall of the thrombosed infrarenal component of the TAAA without aortic clamping
followed by thrombectomy of the thrombosed aorta, and debranching of the visceral arteries. Finally, the thoracic
endovascular aortic repair (TEVAR) can be deployed from within the ABFB graft to exclude the TAAA completely.
We believe this technique should be considered in patients presenting with TAAA with extensive infrarenal aortic
thrombosis and those who are not candidates for fenestrated/branched TEVAR or chimney technique especially in
high risk patients for conventional open repair and aortic clamping. This procedure shares the common basis of a
classical hybrid procedure; we therefore believe that it is safe, effective, and associated with less morbidity and
mortality rates compared to open surgical techniques. However, the long-term results for this new technology still
need to be validated.
Abou Al-Shaar H et al. 7
References
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2.
Canaud L, Karthikesalingam A, Jackson D, et al. Clinical outcomes of single versus staged hybrid repair
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approach. Ann Thorac Surg 2013; 96(4): 1496-1498.
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Safi HJ, Hess KR, Randel M, et al. Cerebrospinal fluid drainage and distal aortic perfusion: reducing
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14. Rigberg DA, McGory ML, Zingmond DS, et al. Thirty-day mortality statistics underestimate the risk of
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Abou Al-Shaar H et al. 9
Figure Legends
Figure 1: An illustration showing large type III Crawford thoracoabdominal aneurysm (TAAA) with extensive
infrarenal segment thrombosis and left renal artery occlusion (A). Axial computed tomography angiogram (CTA)
showing the distal aorta measuring 65 mm (B), supraceliac aorta (C), right renal artery stenosis and left renal artery
occlusion with left renal atrophy (D), and thrombosed infrarenal component of the TAAA measuring 42 mm (E).
Figure 2: Sagittal (A) and coronal (B) computed tamography angiogram (CTA) demonestrating the large type III
Crawford thoracoabdominal aneurysm (TAAA) with extensive infrarenal segment thrombosis and left renal artery
occlusion. 3D angiography (C) and digital subtraction angiography (D) showing the large TAAA with infrarenal
thrombosis and prominent left renal atrophy.
Figure 3: Intraoperative exposure showing the aortobifemoral, aorto-renal, and aorto-celiac/superior mesenteric
artery (SMA) bypass grafts (A). Anastomosis of the graft to the celiac artery (B). Anastomosis of the graft to SMA
and right renal artery (C).
Figure 4: Intraoperative angiogram showing the re-establishment of the aortic blood flow through the stent graft
with complete exclusion of the aneurysm.
Figure 5: Normal blood flow in the SMA, celiac trunk (A), and right renal artery (B) is demonstrated on the
intraoperative angiogram after retrograde graft revascularization of these vessels.
Abou Al-Shaar H et al. 10