Aortic coarctation and descending aortic aneurysm involving the subclavian artery: Hybrid approach to treatment

İbrahim Özsöyler; Hasan Uncu; Hacı Ali Uçak; Mehmet Acıpayam; Dilek Uçak

doi:10.5606/e-cvsi.2014.167

Abstract

Aortic aneurysms are complex and difficult to treat conditions and are associated with high mortality rates. Alternative methods of treatment continues to show development day by day. One of them is the main subject of this article: the hybrid operation. Herein, we present the case of hybrid repair in a 37-year-old female with 56 mm descending aortic aneurysm and aortic coarctation Aortic debranching, carotid-to-subclavian bypass, and thoracic endovascular aortic repair (TEVAR) operations were performed sequentially in this case. The follow-up computed tomography angiography demonstrated thrombus formation in the aneurysm lumen, no endoleak, and the aortic arch and bypass graft were all patent.

Keywords:

Aortic coarctation, descending aorta aneurysm, hybrid procedure, thoracic endovascular aortic repair

Introduction

Treatment of aortic aneurysms is performed by less invasive methods with the growing experience and knowledge of hybrid procedures and the developments in recent years.[1-3] Conventional surgical methods still have total circulatory arrest caused by neurological complications and high mortality and morbidity rates are reported.[4,5] Hybrid approach continues to evolve with each passing day. Arch hybrid procedures include three basic approaches: (i) debranching of aortic arch and anastomosis; (ii) preparation of the proximal and distal landing zones; (iii) thoracic endovascular aortic repair (TEVAR). Stenting procedure can also be performed together or sequentially in different sessions. In this case report, we present a hybrid two-stage surgical procedure in a patient with descending aorta aneurysm involving subclavian artery and postductal coarctation of the aorta.

Case Presentation

A 37-year-old female patient was admitted with complaints of back pain. On physical examination, her blood pressure (BP) measurements were 123/97 mmHg and 114/92 mmHg at her right and left arm, while 84/67 mmHg and 82/65 mmHg at her right and left ankle. Chest X-ray showed a calcified mass and then transthoracic echocardiography was performed. On echocardiography, aortic coarctation with 38 mmHg peak gradient and aneurysm of the descending aorta was detected. Thoraco-abdominal computed tomography angiography, coronary angiography, and aortography was performed (Figure 3, Figure 4). According to the Ishimaru classification, aortic coarctation and descending aortic aneurysm localized zone 2 and zone 3 (Figure 1) was identified (Figure 2). Bilateral carotid and vertebral artery Doppler ultrasonography showed no pathology.

Surgery was performed under general anesthesia with cerebral oximetry monitoring by nearinfrared reflectance spectroscopy (NIRS). Heparin administrated to maintain activated clotting time (ACT) over 300 s. Median sternotomy was performed and innominate vein agenesis was observed. An additional anatomical variations or venous anomaly was not detected. Truncus brachiocephalicus and left common carotid artery were explored.

The left subclavian artery was located in the aneurysm site. Aorta-to-left common carotid and aorta-to-truncus brachiocephalicus bypass operations were performed with side clamping by using 7/14 mm Y-shaped Dacron graft without cardiopulmonary bypass (Figure 5). Zone of the stent will be placed on the ascending aorta were marked with wire of pacemaker.

At the same session, left common carotid-to-left subclavian artery bypass surgery was also performed.

The left femoral artery was explored before the end of the operation for TEVAR. Artery calibration viewed approximately 10 mm. The patient after surgical procedures was taken to angiography unit. A 20 mm self-expandable nitinol stent (E-XL Endoluminal Aortic Stent Prosthesis 20x30 mm, JOTEC GmbH, Hechingen, Germany) was deployed across the coarctation and aneurysm site without previous balloon dilatation procedure. The proximal end of the stent to the ascending aorta and distal end of the stent was placed to distal zone of coarctation site (Figures Figure 6, Figure 7).

No further balloon dilatation was done immediately after the stent deployment to avoid unnecessary tissue injury. There was no endoleak at the end of the procedure and the patient was taken to the intensive care unit. The patient was discharged at the sixth postoperative day. At two months and every six months, follow-up was scheduled and no endoleak was observed.

The BP measurement of four limbs evaluated (Table 1).

Discussion

With the introduction of developments in the treatment of aortic aneurysms in the last 10 years, less invasive methods can be used. These processes performing without cardiopulmonary bypass and hypothermic cardiac arrest attracts the complication rates, morbidity and mortality rates linked to aneurysm surgery down.[6,7] The hybrid method combining cardiovascular surgery and catheterization procedures has been rapidly spreading all over the world. There are publications showing that hybrid method is effective in cases of dissections, ruptures requiring an emergency intervention, and elective cases.[8] Proximal landing zone is the distal site of left subclavian artery, therefore it is zone 2 (Z 2) or zone 3 (Z 3). It may be possible, if the aneurysm is localized in the distal site of the left subclavian artery or thoracic aortic aneurysm or in some cases of type B dissections. If the pathology located proximally, left common carotid-to-left subclavian artery bypass surgery should be performed. In the literature, TEVAR procedures to fix the complications developing secondary to the coarctation surgery performed.[9,10] Hybrid treatment of a newly diagnosed coarctation together with an aneurysm of descending aortic is less invasive and safer than convantional surgery.

Declaration of conflicting interests

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding

The authors received no financial support for the research and/or authorship of this article.

References

Gkremoutis A, Schmandra T, Meyn M, Schmitz-Rixen T, Keese M. Hybrid Approach to Emergent and Urgent Treatment of Complex Thoracoabdominal Aortic Pathology. Eur J Vasc Endovasc Surg 2014;48:407-13.

Kollias VD, Lozos V, Angouras D, Toumpoulis I, Rokkas CK. Single-stage, off-pump hybrid repair of extensive aneurysms of the aortic arch and the descending thoracic aorta. Hellenic J Cardiol 2014;55:355-60.

Ingrund JC, Nasser F, Jesus-Silva SG, Limaco RP, Galastri FL, Burihan MC, et al. Hybrid procedures for complex thoracic aortic diseases. Rev Bras Cir Cardiovasc 2010;25:303-10.

Harrington DK, Walker AS, Kaukuntla H, Bracewell RM, Clutton-Brock TH, Faroqui M, et al. Selective antegrade cerebral perfusion attenuates brain metabolic deficit in aortic arch surgery: a prospective randomized trial. Circulation 2004;110(11 Suppl 1):II231-6.

Westaby S, Katsumata T, Vaccari G. Arch and descending aortic aneurysms: influence of perfusion technique on neurological outcome. Eur J Cardiothorac Surg 1999;15:180-5.

Zhou W, Reardon M, Peden EK, Lin PH, Lumsden AB. Hybrid approach to complex thoracic aortic aneurysms in high-risk patients: surgical challenges and clinical outcomes. J Vasc Surg 2006;44:688-93.

Stone DH, Brewster DC, Kwolek CJ, Lamuraglia GM, Conrad MF, Chung TK, et al. Stent-graft versus opensurgical repair of the thoracic aorta: mid-term results. J Vasc Surg 2006;44:1188-97.

Settembrini A, Mazzaccaro D, Stegher S, Occhiuto MT, Malacrida G, Nano G. Ruptured hemiarch and descending thoracic aorta aneurysm: hybrid treatment. J Cardiothorac Surg 2012;7:66.

Yazar O, Budts W, Maleux G, Houthoofd S, Daenens K, Fourneau I. Thoracic endovascular aortic repair for treatment of late complications after aortic coarctation repair. Ann Vasc Surg 2011;25:1005-11.

Midulla M, Dehaene A, Godart F, Lions C, Decoene C, Serge W, et al. TEVAR in patients with late complications of aortic coarctation repair. J Endovasc Ther 2008;15:552-7.