Endovascular repair of an aortic arch pseudoaneurysm with double chimney stent grafts: a case report
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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.
KeywordsPseudoaneurysm Aortic arch Stent graft Endovascular repair
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, 2, 3, 4, 5, 6, 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, 2, 3, 4, 5, 6, 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, 4, 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, 16, 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.
- 14.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.CrossRefPubMedPubMedCentralGoogle Scholar