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Disruptive endovascular technology with multilayer stents as a therapeutic option in the management a thoracoabdominal aortic aneurysms

Thursday, 22 September, 2011 - 12:40
Board

Patients with thoraco-abdominal Aortic Aneurysm Crawford Type II were classically treated by open surgical repair since 1955 by Etheridge and Rob (1). Such an operation for extensive TAAA still remains a surgical challenge, because extensive TAAA is an independent risk factor for mortality and its mortality (2). Another more recent, less invasive option is the hybrid procedure which consists of two stages, first is visceral debranching of the aorta and second is endovascular exclusion of the previously debranched aortic aneurysm. Full endovascular repair is applicable now with fenestrated grafts and branched grafts (3) or multi layered stent.
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Vascular Surgery

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Introduction

Patients with thoraco-abdominal Aortic Aneurysm Crawford Type II were classically treated by open surgical repair since 1955 by Etheridge and Rob (1). Such an operation for extensive TAAA still remains a surgical challenge, because extensive TAAA is an independent risk factor for mortality and its mortality (2). Another more recent, less invasive option is the hybrid procedure which consists of two stages, first is visceral debranching of the aorta and second is endovascular exclusion of the previously debranched aortic aneurysm. Full endovascular repair is applicable now with fenestrated grafts and branched grafts (3) or multi layered stent.Clinical History

A 76 years old lady, ASA IV, was presented to our service with thoraco-abdominal aortic aneurysm Crawford Type II.

Patient had NSTEMI 1 year ago and ECHO showed prominent aortic root and dilated ascending aorta 4.4 cm 5.9 cm from aortic valve.

She has past medical history of severe COPD –steroid dependent-, Hypertension, Dyslipidaemia, Auto immune Hypothyroidism and Idiopathic Angioedema.

She is non smoker, social drinker and fully independent. She is allergic to Penicillin.Management

CTA Aorta showed a 4.7cm thoraco abdominal aortic aneurysm Crawford Type II. Active surveillance programme was implemented and follow up in OPD, U/S 6 monthly and annual CTA Aorta were performed. One year later the aneurysm reached the size of 6.5cm.

Open or Hybird repair with de-branching followed by TEVAR/EVAR were excluded because of the co morbidities and high mortality rate of the procedure. Her TAA Aneurysm was not suitable to be managed by branched endovascular graft (4).

The patient had a multi-layered stent covering the whole aneurysm and all visceral vessels. 1 day post operatively her duplex scan showed the Aorta shrunk to 2.46cm in the mid-distal abdomen with no obvious aortic sac visualized and no obvious endoleak. She was discharged home on second postoperative day well. Follow up CTA Aorta showed all the visceral branches are patent with good flow. Maximum thoracic aortic diameter shrank to 4cm.

Mechanism of ActionIn an aneurysm with a branch the whole flow entering the aneurysm is aspirated by the branch by negative pressure and no flow stagnates along aneurysmal wall which leads to wall falls down and eventually shrinking of the aneurysm

Conclusions

Multilayered stents may divulge a resolution in such complex thoraco-abdominal aneurysm. Treating the aneurysm sac rather than excluding it may be the future management opportunity (5)References1.Etheredge SN, Yee J, Smith JV, Schonberger S, Goldman MJ. Successful resection of a large aneurysm of the upper abdominal aorta and replacement with homograft. Surgery 1955;38:1071–81

2.Coselli JS, LeMaire SA, Conklin LD, Koksoy C, Schmittling ZC. Morbidity and mortality after extent II thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 2002;73:1107–16

3.Black SA, Wolfe JH, Clark M, Hamady M, Cheshire NJ, Jenkins MP. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization. J Vasc Surg. 2006 Jun;43(6):1081-9

4.J. A. Elefteriades, Natural history of thoracic aortic aneurysms: indications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg 2002;74:S1877-S1880

5.C. Wailliez, G. Coussement, CFD study of multilayer stent haemodynamics effects in abdominal aortic aneurysms, Facult´e Polytechnique de Mons, Fluids-Machines Department