Endovascular management of thoracic aortic aneurysms. Preoperative imaging and device sizing

Balloon expandable aortic stent-graft for the treatment of aortic aneurysm and rupture in a dog

OBJECTIVE

To describe the successful placement of an aortic stent graft in a dog suffering from aortic aneurysm and rupture.

CASE SUMMARY

A 4-year-old neutered female mixed breed dog weighing 25 kg was presented with a chief complaint of acute onset of weakness and respiratory distress. On presentation, the dog was lateral and unresponsive, hypothermic, tachycardic, and tachypneic. Pleural effusion was identified in the right hemi-thorax on thoracic-focused sonographic scan for trauma. Thoracic radiographs showed a fluid/soft tissue opacity in the cranial mediastinum and pleural effusion on the right side. Thoracocentesis yielded noncoagulating blood. Hematology revealed normal PCV and total plasma protein that decreased within 24 hours to 20% and 50 g/L (20%/5.0 g/dL), respectively. The dog was treated with IV fluids, tranexamic acid, and fresh frozen plasma. An aortic aneurysm with irregular mineralization of the right ventrolateral aortic wall was identified on computed tomography examination, which also demonstrated a peri-aortic hematoma. A decision was made to attempt treatment with a stent graft. Under general anesthesia, a marker catheter was inserted into the esophagus. A 10-Fr sheath was inserted into the right femoral artery, and an angiography catheter was advanced over a wire. After angiography, a stent graft (12-mm × 50-mm) was placed over the guide wire and deployed under fluoroscopic guidance. The dog recovered uneventfully, with no evidence of recurrent bleeding, and was discharged 2 days after the procedure with antimicrobials, anthelmintic, and antithrombotic treatment. At 90-day follow-up, the dog was doing well, and stent position was radiographically confirmed.

NEW OR UNIQUE INFORMATION PROVIDED

This report describes successful management of aortic aneurysm and dissection, an uncommon and challenging pathology in the veterinary practice with few available treatment options. Stent graft placement is a minimally invasive procedure in which a covered stent is placed over the lesion to prevent rupture.

Endovascular Repair For Thoracic Aortic Disease: Tertiary Single-center Experience In Northwestern Greece

The purpose of this article is to report the initial experience with endovascular repair of thoracic aortic disease in a single tertiary vascular unit in northwestern Greece.

Between 2003 and 2005, 16 patients were treated with endovascular techniques for various pathologies of the descending thoracic aorta. Twelve patients were treated electively and four emergently. Operative and follow-up data for a mean time of 18.4 months were retrospectively collected and analyzed.

Primary technical success was obtained in 14 (87.5%) cases. No early or late deaths occurred, and there was no major operation-related complication. No paraplegia was observed in our patients. Stent graft–related complications occurred in 18.75% (one type 2 and two type 3 endoleaks), but they all had a favorable outcome. No further problems have been reported in any of our patients.

Endovascular stent graft repair for diseases of the thoracic aorta seems to be a promising alternative to open surgery, especially for high-risk patients. Long-term results are needed to confirm the early benefit of this treatment option with regard to morbidity and mortality rates. The potential of this technique to be applicable even in relatively small, tertiary vascular centers might be of great benefit to patients.

[Is endovascular treatment of acute thoracic aortic disease possible in centers where extracorporal circulation is not available?]

OBJECTIVE

To determine whether access to extra-corporal circulation (ECC) is necessary to treat acute descending thoracic aorta disease.

METHOD

From January 2004 to May 2006, 16 patients underwent endovascular stent-graft repair of the descending thoracic aorta, among them 13 (81%) were treated in an emergency setting (nine men, mean age: 75.4 years, range 30-94 years). The indication was traumatic aortic rupture (n=3, 23%), complicated acute type B dissection (n=4; 31%), symptomatic or ruptured thoracic aortic aneurysm (n=4; 31%), aorto-esophageal fistula (n=1; 7,5%) and aortic intramural haematoma (n=1; 7,5%). Computed tomography showed hemomediastin and/or hemothorax in five patients (38%). Transesophageal echocardiography and angiography were performed in two (15%) and one patients respectively. Cerebrospinal fluid drainage was performed for two patients (15%).

RESULTS

Endovascular repair was successfully completed in 92.3% of cases. The 30-day mortality was 7.5% (n=1). There was one case (7.5%) of delayed paraplegia. Follow-up ranged between two and 24 months (mean 10.2), no rupture occurred. Three type I endoleaks were detected and only two were treated. Two none related additional mortalities were observed. None of these patients has needed ECC.

CONCLUSION

The unavailability of ECC does not seem to be a compromising factor in the management of thoracic aorta disease, however a good experience in endovascular techniques is required.

Endovascular Repair of a Thoracic Aortic Injury in a Burn Patient

Mortality in burn patients who sustain concomitant mechanical traumatic injuries at the time of thermal injury is greater than in patients who sustain isolated injuries. Invasive interventions to treat these mechanical traumatic injuries may be a source of added mortality and contribute to an injury-induced state of immunosuppression. Less-invasive interventions may minimize morbidity and mortality and allow for improved recovery from thermal injury. A case is presented of a patient who sustained 20% TBSA electrical burns and an acute thoracic aortic injury near the diaphragmatic hiatus. Abdominal aortic stent-graft components were used to successfully exclude the patient's thoracic aortic injury. The patient made a successful recovery from his burns and sustained no infectious complications. This case report highlights the potential advantages of endovascular therapy for the treatment of aortic trauma in patients who sustain concomitant burn injuries.