Endovascular Stent Grafting of Descending Thoracic Aortic Aneurysm

An 89-year-old woman presented to emergency department with an acute onset of midsternal chest pain radiating to the back. Her medical history was significant for coronary artery disease, hypertension, diabetes mellitus, chronic renal insufficiency, and an abdominal aortic aneurysm that had been repaired about 5 years earlier. A coronary angiogram performed 1 year prior to presentation had shown a 50% ostial left main coronary artery stenosis and a 70% proximal left anterior descending coronary artery stenosis. The patient’s condition had been managed medically since then. During this hospitalization, the findings of serial 12-lead ECGs and cardiac enzyme tests were negative for acute myocardial injury or ischemia. A chest roentgenogram revealed a dilated aorta and a left pleural effusion. Subsequently, an enhanced CT scan was performed that showed a large thoracic aortic aneurysm with paraaortic hematoma, which is indicative of a contained rupture, and a left pleural effusion. IV beta-blocker therapy was initiated. The patient continued to complain of chest pain and developed increasing dyspnea. A repeat chest roentgenogram demonstrated worsening of the left pleural effusion. Therapeutic options including operative intervention were discussed with the patient and the family. High-risk comorbidities with an American Society of Anesthesiologists grade IV risk precluded the option of thoracotomy, and an endovascular approach with stent-graft prosthesis seemed to be an alternative option.

Under general anesthesia, the right femoral artery was exposed and an introducer sheath was inserted into the aorta for endograft insertion. The left femoral artery was percutaneously punctured for diagnostic angiography. Aortography with a calibrated catheter confirmed the preoperative finding of large descending thoracic aortic aneurysm and, distal to this, a thoracoabdominal aneurysm (Fig 1). The right transfemoral approach was unsuccessful due to an insufficient ileofemoral diameter that was complicated by an external iliac artery rupture (which required patch angioplasty). Then, the left femoral artery was exposed, and, through an introducer sheath under fluoroscopic control, the insertion of the endograft was successful. However, because of the severe angle of the aortic arch, the endograft could not track the superstiff wire. A percutaneous puncture was made in the right brachial artery, and a long guidewire was passed from the right brachial artery to the left femoral artery (with through-andthrough wire). By applying tension on both ends of the wire, the endograft could track the wire. In order to facilitate accurate deployment, the heart was stopped using 36 mg adenosine. Under temporary cardiac arrest, self-expanding endovascular stent prostheses (AneuRx; Medtronic; Minneapolis, MN) were deployed in the optimal position (Fig 2). The dimensions of the endograft were 28 mm in diameter and 3.75 cm in length, and a total of 11 endografts were deployed. An angiogram performed after completion confirmed the proper position of stent-grafts and the complete exclusion of the large descending thoracic aortic aneurysm with no signs of endovascular leak (Fig 3). The aneurysm in the distal portion of the descending thoracic aorta was not treated due to its close proximity to the celiac artery, and also it was considered not to be life-threatening. There were no neurologic deficits. The postoperative course was uneventful, and patient was discharged from the hospital on the fifth postoperative day.