Extended applications of thoracic aortic stent grafts.

BACKGROUND: Thoracic stent-grafts (TSG) show excellent early and mid-term results for localized diseases of the descending aorta. Extending TSG applications for arch pathologies or to other yet unproven indications remains to be established. We herein report our experience in 18 patients with extended applications of TSG. METHODS: Ten patients with inadequate proximal aortic neck length required coverage of at least one arch vessel with or without extra-anatomic bypass. One patient required an extra-anatomic visceral bypass to extend the distal aortic neck, 6 patients were treated with TSG for yet unproven indications, and 1 patient required an unusual vascular access. RESULTS: A mean of 2.4 +/- 1.0 stents per patient were inserted. Primary or secondary success rate was 100%. Hospital mortality occurred in one patient (5.5%). Mean follow-up was 24.1 +/- 13.7 months. Four endoleaks were diagnosed: two of type 1, one of type 2, and one that remains undetermined. Two patients died during follow-up; both deaths were linked to the presence of a type 1 endoleak. Actuarial survival at 3 years was 79.0%. Freedom from endoleak and stent-graft-related death at 3 years were, respectively, 71.0% and 83.7%. No stent-graft migration was observed. CONCLUSIONS: Early and mid-term results of extended applications of TSG are acceptable in well-selected high-risk patients. Endoleak at follow-up remains a concern and may impede long-term outcome of TSG in complex procedures.

Endovascular treatment of a blunt thoracic aortic laceration due to thoracolumbar spine fracture.

A 36-year-old woman sustained an aortic laceration at the level of the diaphragmatic hiatus owing to a displaced thoracolumbar spine fracture (TLS). We herein report the first case of aortic trauma secondary to a TLS fracture treated with a thoracic stent-graft.

Changing trends in management of thoracic aortic disease: where do we stand with thoracic endovascular stent grafts?

BACKGROUND: Descending thoracic aortic surgery is linked to a high morbidity and mortality. Thoracic endovascular stent grafts were designed to decrease perioperative risks, especially in patients with severe comorbidities. However, procedure-related complications and clinical outcomes remain ill-defined. PATIENTS AND METHODS: The authors' experience in 24 patients (mean age 63.3+/-25.4 years) from May 2001 to February 2004 is reported. The diagnosis was thoracic aneurysm in 10 patients, complicated penetrating aortic ulcer in six patients, blunt traumatic aortic rupture in four patients, complicated type B dissection in two patients, and aortoesophageal fistula and postoperative pseudoaneurysm in one patient each, respectively. Symptoms were present in 15 of 24 patients (62.5%). The decision to implant a thoracic endovascular stent graft was based on significant coinjuries in three patients, severe comorbidities in 16 patients and patient decision in five patients. RESULTS: The mean operative time was 2.3+/-1.7 h and the mean number of stents per patient was 1.8+/-0.7. Six patients required coverage of the left subclavian artery without complications. A carotid-carotid bypass was required in two patients. In one patient, a thoracic endovascular stent graft was introduced through a 10 mm graft anastomosed to the distal descending aorta accessed through a video-assisted minithoracotomy. Perioperative complications were an arterial access problem in one patient and pneumonia in four patients. The primary success rate was 100%. An 82-year-old patient with a ruptured thoracoabdominal aneurysm died of multi-organ failure (4.1% hospital mortality). All 23 surviving patients were alive at 13.4+/-3.5 months. One patient required an additional procedure for recurrent hematemesis. CONCLUSIONS: Thoracic endovascular stent grafts show excellent early results in well-selected cases. Extra-anatomical bypass or novel vascular access procedures increase the applicability of thoracic endovascular stent grafts. Meticulous follow-up is essential to identify and treat stent graft-related complications. Data on long-term outcomes are required before applying thoracic endovascular stent grafts to patients with a lower operative risk.

Endovascular stent-graft repair of a complicated penetrating ulcer of the descending thoracic aorta: a word of caution.

PURPOSE: To report a pitfall encountered during stenting of a complicated penetrating ulcer of the descending thoracic aorta. CASE REPORT: A 65-year-old man was diagnosed with a complicated penetrating ulcer of the thoracic aorta. A 38-mm Talent endograft was implanted. On balloon dilation of the distal end of the endoprosthesis, the terminal bare stent became distorted and penetrated the aortic wall. A 42-mm endoprosthesis was immediately placed to exclude the aortic perforation. Control aortography demonstrated exclusion of the original proximal aortic ulcer and the distal iatrogenic aortic tear. CONCLUSIONS: Endoprostheses may present some drawbacks in terms of elasticity and adaptability to tortuous and angulated diseased aortas. Caution is advised in the treatment of penetrating aortic ulcers where the aortic wall is diffusely friable. In this condition, balloon dilation should be limited to the covered portion of the stent-graft to prevent stent distortion and erosion through the aortic wall.

Delayed treatment of contained blunt traumatic aortic rupture: a case of rupture treated by endoprosthesis.

A 45-year-old man sustained an intracerebral frontal hematoma and a contained aortic isthmic rupture in a head-on automobile collision. Due to the intracerebral hemorrhage, open repair was contraindicated. Treatment with a stent graft was selected but delayed until the next morning, because the correct stent size was unavailable. Two hours before the time scheduled for surgery, the patient experienced oxygenation problems and became hypotensive. Chest radiography revealed a new, severe left hemothorax. Fortunately, the stent graft had just arrived from the manufacturer, and it was deployed to seal the ruptured aorta. Immediate angiography showed good stent-graft position without any endoleak as did a computed tomographic scan 2 days after the procedure. The patient was transferred to a rehabilitation unit to recover from his neurologic trauma. A 3-month follow-up computed tomographic scan showed the patient's condition to be unchanged.