Endovascular Repair Of Thoracic Aortic Emergencies

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Manish Mehta, MD, MPH, R. Clement Darling, III, MD, Sean P. Roddy, MD, Benjamin B. Chang, MD, Philip S.K. Paty, MD, Kathleen J. Ozsvath, MD, Yaron Sternbach, MD, Dhiraj M. Shah, MD.
Albany Medical College, Albany, NY, USA.

Objective:
To evaluate the feasibility and efficacy of endovascular repair of thoracic aortic emergencies with commercially available aortic stentgrafts.
Methods:
From January 2004 to July 2005, 29 patients with ruptured thoracic aortic aneurysms or transections had emergent endovascular repair via femoral (n=17, 59%) or iliac (n=12, 41%) approach with use of commercially available TAG-Gore (n=11, 38%), or Zenith-Cook abdominal aortic (n=18, 62%) stentgrafts. Prior to FDA approval of the TAG device, Zenith-Cook modular bifurcated stentgrafts were tailored during the procedure to create tubular devices and re-loaded into appropriately sized sheaths to match the patient’s anatomy. Patients that required coverage of the left subclavian artery to facilitate proximal stentgraft fixation underwent carotid subclavian bypass.
Results:
Endovascular procedures were performed urgently in 22 (76%) patients and emergently in 7 (24%) patients for thoracic aortic aneurysm rupture (n=19, 68%), ruptured penetrating thoracic aortic ulcer (n=4, 14%), thoracic aortic anastomotic pseudoaneurysm to bronchial fistula (n=4, 14%), and traumatic thoracic aortic transaction (n=2, 7%). Primary technical success, defined as successful deployment and exclusion of the lesion without evidence of Type I or Type III endoleak, was achieved in all 29 patients. During the follow-up period, stentgraft migration from distal fixation site and a resulting Type I endoleak developed in 1 (4%) patient, and Type III endoleak developed 1 (4%) patient; both were treated by endovascular means. Two (7%) patient had a type II endoleak without adverse consequence. Postoperative complications included myocardial infarction (n=3, 11%), renal failure (n=3, 11%), stroke (n=2, 7%), paraplegia (n=2, 7%). Two (7%) patients had intraoperative iliac artery rupture; one was treated by a stentgraft, and the other required iliofemoral bypass. Two (7%) patients required adjunctive carotid-subclavian bypass, and 3 (11%) patients died secondary to multisystem organ failure.
Conclusion:
In select patients, endovascular repair of ruptured thoracic aortic aneurysms and traumatic aortic transections using commercially available and tailored abdominal aortic stentgraft is feasible and associated with a limited and acceptable morbidity and mortality.

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