Interact CardioVasc Thorac Surg 2008;7:269-271. doi:10.1510/icvts.2007.172593
© 2008 European Association of Cardio-Thoracic Surgery
Proposal for bail-out procedures - Vascular thoracic |
Use of the right brachio-femoral wire approach to manage a thoracic aortic aneurysm in an extremely angulated and tortuous aorta with an endoluminal stent graft
Jacques Kpodonua,*,
Julio A. Rodriguez-Lopezb,
Venkatesh G. Ramaiahb and
Edward B. Diethrichb
a Division of Cardiac Surgery, North Western Memorial Hospital, 201 East Huron Street, Galter 11-140, Chicago, IL 60611, USA
b Department of Cardiovascular and Endovascular Surgery, Arizona Heart Hospital and Arizona Heart Institute, Phoenix, AZ, USA
Received 28 November 2007;
received in revised form 31 December 2007;
accepted 1 January 2008
*Corresponding author. Tel.: +1-312-695-3121; fax: +1-312-695-1903.
E-mail address: jkpodonu{at}yahoo.com (J. Kpodonu).
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Abstract
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The presence of a tortuous, elongated thoracic aorta and an angulated arch poses a technical challenge for the delivery of an endoluminal graft to the target site to exclude management of a thoracic aortic aneurysm. Despite the availability of a flexible delivery sheath system, adjunct techniques are necessary to deal with extremely tortuous thoracic aortas. The use of a brachio-femoral wire with tension applied at both ends is a useful technique to deliver an endoluminal graft in an angulated thoracic arch. We describe the use of a right brachio-femoral wire approach to treat a thoracic aortic aneurysm in a 75-year-old man with an elongated, tortuous and angulated arch aorta.
Key Words: Thoracic aneurysm; Endoluminal graft; Brachio-femoral wire
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1. Introduction
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Endovascular management of thoracic aortic aneurysms are associated with decreased morbidity and mortality compared to open surgical techniques. The tortuous, enlongated and angulated arch may make it difficult to advance an endoluminal graft to its target site. We describe a technique that can safely be used to advance an endoluminal graft up the hostile and tortuous arch.
A 75-year-old man with a past medical history significant for hypertension, hyperlipidemia, coronary artery disease, chronic obstructive lung disease, and prostate cancer post radiation therapy was found to have a 7.0 cm thoracic aortic aneurysm (Fig. 1a) for symptoms of back pain. He was considered high risk for open surgical repair and offered an endovascular approach to manage the aneurysm.
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Fig. 1. (a) CT scan of the chest demonstrating a thoracic aortic aneurysm with a diameter of 7.0 cm. (b) Postoperative CT scan demonstrating exclusion of thoracic aortic aneurysm with no visualized endoleak.
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2. Endovascular technique
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Placement of bilateral arterial radial arterial lines, open retrograde of the right common femoral artery with placement of a 9F sheath and percutaneous retrograde access of the left common femoral artery with a 5F sheath were performed. 5000 units of heparin was given and iliac angiogram performed demonstrated diffuse stenosis and calcification of both common and external iliac arteries which was successfully managed with balloon angioplasty. An oblique thoracic aortogram performed through a 5F angiographic pig-tail catheter demonstrated a thoracic aortic aneurysm juxta distal to the left subclavian artery with a very tortuous angled arch (Fig. 2a). Using intravascular ultrasound the proximal neck diameter at the level of the left carotid artery measured 31 mmx24 mm and a distal neck diameter at the level of the celiac trunk measured 27 mmx24 mm. Due to the extreme tortuousity of the thoracic arch aorta, it was evident that a thoracic endograft would not be able to negotiate the aortic arch curve and a brachio-femoral wire conduit technique would be required to help navigate the tortous aortic arch. A retrograde percutaneous right brachial approach was therefore performed with a 6F 35 cm sheath and a 5F Bernstein catheter was used as a guiding catheter to navigate a 260-cm length 0.035-inch angled glide wire into the tortuous descending thoracic aorta under fluoroscopic guidance (Fig. 2b). The wire was subsequently secured through the right groin sheath with the help of a snare. A glide catheter was used as an exchange catheter and the 260 cm length 0.035 inch glide wire was exchanged to a stiff 260 cm length 0.035 inch Lunderquist wire (Cook Bloomington, IN, USA). The 9F sheath in the right groin was exchanged to a 22 F Gore sheath, which was advanced into the distal abdominal aorta. A road map angiogram was obtained through the left groin sheath pig-tail catheter. By keeping a constant tension on the brachio-femoral wire conduit from the right brachial end and the right common femoral end, a 34 mmx20 cm Gore TAG (W.L. Gore & Associates, Flagstaff, AZ, USA) device was advanced through the tortuous descending aorta into the arch and deployed distal to the left carotid artery partially covering the left subclavian artery (Fig. 2c). A 31 mmx15 cm Gore –TAG device was subsequently deployed distally just above the celiac trunk after an aortogram had been performed to demarcate the distal landing zone on the road map. A third device, 34 mmx15 cm Gore TAG device, was necessary to cover the area of overlap between the proximal and distal endografts. A completion angiogram demonstrated successful exclusion of the thoracic aortic aneurysm with no endoleak (Fig. 2d). The 22F sheath was then exchanged to a 9F sheath and bilateral iliac angiograms demonstrated no extravasation of contrast. Bilateral 10 mmx37 mm self-expandable stents were subsequently deployed at the area of previous iliac artery balloon angioplasty. Completion angiogram demonstrated satisfactory angiographic pictures with brisk flow through the iliac vessels and no pressure gradient. Sheaths and wires were removed and the right common femoral artery repaired and a closure device deployed to the left common femoral artery. The patient was extubated and transferred to the recovery room. A postoperative CT scan (Fig. 1b) demonstrated no endoleak with exclusion of thoracic aortic aneurysm.
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Fig. 2. (a,b) Angiogram and illustration demonstrating an extremely angulated arch with a large thoracic aortic aneurysm and a brachio-femoral wire. (c) Illustration of endoluminal graft deployed using a brachio-femoral wire. (d) Completion angiogram demonstrating exclusion of thoracic aortic aneurysm with no demonstrable endoleak.
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3. Discussion
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Despite improved surgical techniques, the operative mortality with open surgical repair of descending thoracic aortic aneurysms is between 4.8% and 20% [1, 2]. Many authors [3, 4] have confirmed the decreased morbidity and mortality with thoracic stent grafts to treat thoracic aortic aneurysms. An angulated arch and a tortuous aorta is a relative contraindication for deployment of an endoluminal graft. The use of a super stiff wire may not be sufficient to allow the sheath or the endograft to track proximally into the angulated arch.
Use of brachio-femoral access wires can help straighten the most angulated and tortuous aorta. The technique requires that a protective guiding catheter be placed to protect the subclavian artery from injury. It is important to have at least a 260-cm long wire and constant tension must be placed on both ends of the wire as the graft is advanced through the delivery sheath into the aorta. When applying this technique the prudent surgeon must always ensure that a guidewire remains in the aorta upon removal of a delivery sheath and an aortic occlusion balloon should always be available in the operating room in case of a suspected rupture.
In conclusion, proper preparation with adequate imaging should allow successful and safe endovascular repair of the tortuous and angulated thoracic aorta even in difficult access situations. The technique of a brachio-femoral wire should be used with a guiding sheath protecting the subclavian vessels to prevent shearing the vessel when traction on the wire is exerted and finally this technique does pose an inherent risk of thromboembolism from the arch vessels and should not be performed if imaging demonstrates atheroemboli in the arch vessels for fear of atheroemboli to the brain.
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References
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- Coselli JS, Le Maire SA, Miller CC, Schmittling ZC, Koksoy C, Pagan J, Curling PE. Mortality and paraplegia after thoracoabdominal aortic aneurysm repair (a risk factor analysis). Ann Thorac Surg 2000;69:409–414.[Abstract/Free Full Text]
- Brandt M, Hussel K, Walluscheck KP, Boning A, Rahimi A, Cremer J. Early and long-term results of replacement of the descending aorta. Eur J Vasc Endovasc Surg 2005;30:365–369.[CrossRef][Medline]
- Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729–1734.[Abstract/Free Full Text]
- Greenberg RK, O'Neill S, Walker E, Haddad F, Lyden SP, Svensson LG, Lytle B, Clair DG, Ouriel K. Endovascular repair of thoracic aortic lesions with the Zenith TX1 and TX2 thoracic grafts (intermediate-term results). J Vasc Surg 2005;41:589–596.[CrossRef][Medline]
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Abstract
1. Introduction