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References
Fig. 75.3 Intraoperative aortogram showing large hypogastric aneurysm
hypogastric artery is often necessary in order to
repair hypogastric artery aneurysm. Endovascular
repair is often preferable by coil embolization of
the anterior and posterior branches of the hypogastric artery and endograft coverage at the origin of hypogastric artery [1]. Endografting of the
hypogastric artery aneurysm is usually not feasible because of difculty in having satisfactory
landing zone for the endograft proximally and
distally [2].
The risk of rupture of hypogastric artery aneurysm is high and estimated to be 38% and carries
50–60% mortality. Therefore, hypogastric arteries greater than 3 cm in diameter should be
repaired although a recent study has shown that
hypogastric artery aneurysm should be repaired
only when they reach 4cm in transverse diameter. Repair of a hypogastric artery aneurysm is
dependent on (1) the presence of compressive
symptoms (lumbosacral nerve roots), ureter,
Fig. 75.4 Satisfactory exclusion of AAA and right hypo-
gastric aneurysm and no cross-lling of right hypogastric
aneurysm from the left hypogastric artery
bladder, iliac veins, and rectum, (2) patient’s
medical comorbidities, and (3) status of contralateral hypogastric artery.
333
which showed stable aneurysm sac measuring
4.5×4.6cm without endoleak.
Discussion
Preservation of hypogastric artery is often impossible in patients with hypogastric artery aneurysms. Open repair is difcult because of its deep
location. Ligation of the feeding branches of the
References
1. Sevak S, Long G.Endovascular repair of iliac artery
aneurysm. In: Hans SS, Shephard AD, Weaver MR,
Bove PG, Long GW, editors. Endovascular and open
vascular reconstruction: a practical approach. Boca
Raton: CRC Press; 2018. p.55–61.
2. Parry DJ, Kessel D, Scott DJ. Simplifying the inter-
nal iliac artery aneurysm. Ann R Coll Surg Engl.
2001;83(5):302–8.
Part XX
Thoracic Endovascular Aneurysm Repair
Endovascular Aneurysm Repair
forSymptomatic Abdominal Aortic
Aneurysm Followed by Thoracic
Endovascular Aneurysm Repair
Complicated by Type IB Endoleak
76
Physical Examination
A 77-year-old female was admitted to the hospital with anemia and was evaluated for occult
malignancy and underwent contrast CT scan of
the abdomen on July 30, 2010, which showed
saccular outpouching of lower thoracic aorta
with maximal diameter of aorta above the aortic
hiatus (4.5cm in transverse diameter). In addition, patient had infrarenal abdominal aortic
aneurysm (AAA) which measured 5.5cm in AP
and 5.3cm in transverse dimension. The other
positive nding was dilatation of the extrahepatic common duct to 1.4cm in a patient with
history of cholecystectomy. The dilatation of
the bile duct extended to the head of the
pancreas.
Patient was admitted to the hospital on May
13, 2012, from emergency room with abdominal
pain and underwent CTA of the chest and abdomen which showed aneurysmal dilatation of the
ascending aorta measuring 4.9 cm in its transverse diameter at the root, arch of aorta measuring 3.3cm, and distal descending thoracic aorta
measuring 6×5cm and about 8cm in length. At
the aortic hiatus, aorta measured 3.2 cm in ap
diameter and 3.5cm in its transverse diameter. At
the level of renal arteries, abdominal aorta measured 2.4cm in its ap dimension and 2.5cm in its
transverse dimension. The infrarenal AAA measured 7 cm in its AP diameter and 6cm in the
transverse diameter.
Procedure
Patient underwent urgent endovascular aneurysm
repair (EVAR) on May 13, 2012, for a large symptomatic AAA with Endurant® graft (Medtronic,
Dublin, Ireland). Main body 32×16×166, contralateral limb 16 × 20 × 93, and left iliac limb
extension 20×20×82mm. The contralateral gate
was captured using multiple purpose catheter.
Completion aortogram showed satisfactory exclusion of the AAA with a delayed Type II endoleak
from one of the lumbar arteries (Fig.76.1). Patient
underwent follow-up of the CTA abdomen and
pelvis on July 19, 2011, which showed the aneurysm sac measurement decreased to 5.0×5.3cm.
Patient underwent CTA abdomen and pelvis on
March 9, 2016, as her symptoms on admission
were abdominal pain, weight loss, and constipation. CTA of the chest showed enlarging saccular
descending thoracic aortic aneurysm which measured 7.6×6.2cm in its AP and transverse dimension and 8cm in craniocaudal dimension with a
large amount of thrombus.
Patient underwent thoracic endovascular aneu-
rysm repair (TEVAR) on April 12, 2016, with
®
Valiant
the right side, 5F sheath was introduced percutaneously and on the left side pre-close technique
was performed. Following deployment of the thoracic aortic stent graft angioplasty was performed.
Patient underwent follow-up ultrasound of the
abdomen (June 2015) which showed aneurysm
graft (Medtronic) 38×30×150cm. On
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_76
337
76 Endovascular Aneurysm Repair forSymptomatic Abdominal Aortic Aneurysm Followed by Thoracic…
338
sac measurements of 4.6 × 4.6 cm without evidence of endoleak.
Patient was admitted with generalized weakness, shortness of breath, and left side abdominal
pain and underwent CTA of the chest on November
23, 2017, which showed large IB endoleak from
TEVAR and a small stable IA endoleak post EVAR
(Fig.76.2). The excluded aneurysm sac and thoracic aorta measured 6.2×6.4cm and the abdominal aorta measured 5.4 × 5.2 cm. On April 11,
2018, patient underwent placement of a
38×38×20cm valiant endograft for treatment of
Type IB endoleak with good proximal overlap,
and distal extent of the thoracic endograft was
2cm proximal to the origin of celiac artery. Preclose technique was used for deployment of the
endograft from the right femoral artery. Patient
underwent CTA of the abdomen in June 29, 2019,
which showed satisfactory exclusion of the tho-
Fig. 76.1 CTA of the abdomen and pelvis showing satis-
factory exclusion of AAA
racic endograft with aneurysm sac measuring
8.5cm in its largest transverse diameter (Fig.76.3).
Fig. 76.2 CTA chest Type IB endoleak following TEVAR and small Type IA endoleak following EVAR
Fig. 76.3 CTA chest. TEVAR with resolution of Type IB endoleak. Scatter effect for coils for Type IA endoleak fol-
lowing EVAR
References
339
Abdominal aortic aneurysm measured 5.5×5.1cm
with increasing size of type IA endoleak. As further management options for type IA endoleak
were limited and patient’s medical condition was
poor, she underwent coil embolization of type IA
endoleak using translumbar approach.
Patient underwent follow-up CTA of the abdomen 2weeks later following coil embolization of
Type IA endoleak; however the visualization was
poor due to scatter effect from the coil. It did show
persistence of Type IA endoleak which was
smaller in size. Patient made herself under hospice
care and she died in October 2019. She died
7 years and 4 months following repair of large
symptomatic AAA and in the follow-up period
underwent TEVAR and repair of Type IB endoleak.
Discussion
This case illustrates that careful follow-up is
essential following EVAR as well as TEVAR.Late
development of Type I endoleak and increasing
size of thoracic aortic aneurysm in a patient who
had extensive aneurysmal disease extending from
root of ascending aorta to distal abdominal aorta
is not unexpected. Belvroy etal. reviewed 16 articles on type IB endoleak after TEVAR [1]. They
reported incidence of type IB endoleak was 15%
with a mean follow-up of at least 1year. A tortuous aorta was a predictive factor (aortic tortuosity
index>0.15cm−1). Most patients required treatment (22 of 27) and is usually performed with
distal extension of the stent graft. Joo etal. performed TEVAR in 538 patients between 1994 and
2007 with 34 patients required late conversion to
open repair; 14 patients required circulatory arrest
for aortic arch involvement. The mean interval to
open conversion after TEVAR was 33.9 months
[2]. Indications for late open conversion included
Type I endoleak (14), new intimal tear induced by
stent graft (6), retrograde type A dissection (4),
stent migration and fracture (3), stent graft infection (3), sac enlargement without endoleak (1),
aortopulmonary stula (1), and stent implantation
failure (1). They reported in- hospital mortality of
9.1%; therefore lifelong surveillance is mandatory in patients who undergo TEVAR.
Fairman et al. evaluated 7006 patients from
the national dataset of TEVAR in VQI (2010–
2017) comprising 51.2% with thoracic aortic
aneurysm, 33.5% type B dissection, 7% penetrating aortic ulcer, 6.7% trauma, and 1.6% intramural hematoma. Reintervention rate for
endovascular thoracic aortic aneurysm repair
was 6.7%. The most common cause of reintervention across all aortic disease was Type I
endoleak [3]. The most common long-term intervention was placement of endovascular stent
graft (65%) [3].
References
1. Belvroy VM, DeBeaufort HWL, VanHerwaarden JA,
Trimarchi S.Type 1B endoleak after thoracic endovascular aortic repair are inadequately reported: a systemic review. Ann Vasc Surg. 2020;62:474–83.
2. Joo HC, Kwon JH, Kim JH, Lee S. Late open conversion after thoracic endovascular aortic repair. J Vasc
Surg. 2019;70:439–48.
3. Fairman AS, Beck AW, Malas MB, Goodney PP.
Reintervention in the modern era of thoracic endovascular repair. J Vasc Surg. 2020;71(2):408–22.
Thoracic Endovascular Repair
forRuptured Aberrant Right
Subclavian Artery Aneurysm
Without Subclavian Artery
Revascularization
77
Physical Examination andHistory
An 83-year-old male presented to emergency
room of an outside hospital with shortness of
breath and chest discomfort. Patient had sustained a fall 2days prior to coming to the emergency room at that hospital in October 2018. A
CT scan of the chest showed probable rupture of
aberrant right subclavian artery aneurysm with
associated hemothorax. Patient was recommended CTA of the chest at the outside hospital,
but he left the hospital against medical advice.
As his shortness of breath worsened, he came to
our hospital. Medical comorbidities included
atrial brillation (on apixaban), and remote
stroke with right-sided weakness (ambulating
with the help of cane). Past surgical history
included permanent pacemaker and transurethral
resection of bladder tumor. Patient was rst
diagnosed with aberrant right subclavian artery
aneurysm measuring 2.8 cm in its largest ap/
transverse diameter in January 2008 (Fig.77.1).
In November 2016, CTA of the chest showed
4 cm aberrant subclavian artery aneurysm
(Fig. 77.2). At that time, repair was recommended but patient refused any intervention.
CTA of the chest at this admission (October
2018) showed large aberrant right subclavian
artery aneurysm with contrast extravasation and
right-sided hemothorax (Fig.77.3).
Procedure
Patient underwent thoracic endovascular aneurysm repair (TEVAR) via right femoral artery
cutdown and a percutaneous insertion of a 7 left
femoral sheath. Valiant™ (Medtronic, Dublin,
Ireland) endograft (44 mm × 44 mm × 15 cm
long) was deployed proximal to the origin of
aberrant right subclavian artery aneurysm followed by balloon angioplasty. Completion aortogram showed diminished lling of the aneurysm
sac (Fig.77.4). The patient underwent right subclavian artery coil embolization (AZUR® coils,
Terumo, Somerset, NJ) via percutaneous right
brachial artery approach (Fig.77.5) after deployment of thoracic endograft right tube thoracostomy (28 F) in the sixth intercostal space with
drainage of two liters of serosanguinous uid.
Patient continued to improve, and chest tube was
removed on the third postoperative day.
Patient complained of some pain in the distal
portion of the digits and paresthesia. Doppler
arterial study showed wrist brachial index of
0.38 on the right (normal, 1.0 on the left). Patient
continued to improve, and the wrist brachial
index after 3months increased to 0.53. Patient
was started on fondaparinux which was transitioned to apixaban. CTA of the chest on postoperative day 16th showed satisfactory exclusion
of the origin of the aberrant right subclavian
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_77
341
342
Fig. 77.1 CTA of the chest showing small aberrant right subclavian artery aneurysm (2008)
77 Thoracic Endovascular Repair forRuptured Aberrant Right Subclavian Artery Aneurysm Without…
Fig. 77.2 CTA of the chest showing 4cm aberrant right subclavian artery aneurysm (2016)
Fig. 77.3 CTA of the chest showing ruptured large right aberrant subclavian aneurysm with hemothorax (2018)
Discussion
Fig. 77.4 TEVAR stent graft placed with coverage of the aberrant right subclavian artery, right-sided chest tube placed
with 2L bloody output
343
Fig. 77.5 Right brachial access with coil embolization of the subclavian artery just distal to the aneurysmal sac but
proximal to the internal mammary artery
artery aneurysm (Fig. 77.6). Patient was last
Discussion
seen in November 2019 with a wrist brachial
index of 0.67 with no ischemic symptoms involving the right upper extremity or the hand.
Immediately after placement of thoracic endograft, patient developed thrombocytopenia (heparin induced).
First described in 1735 by Hunauld, the origin of
right subclavian artery, arising from the descending thoracic aorta is one of the most common
congenital anomalies of the aortic arch and
occurs in 0.5–1% of the population. Symptoms
344
Fig. 77.6 Postoperative CTA of the chest showing complete exclusion of right aberrant subclavian artery aneurysm
77 Thoracic Endovascular Repair forRuptured Aberrant Right Subclavian Artery Aneurysm Without…
of aberrant subclavian artery are mostly related to
development of aneurysmal disease which occurs
at its origin. The aneurysm occurs in nearly 60%
of cases of right subclavian artery and is known
as Kommerell’s diverticulum. Verzini et al.
reported the results from a multicenter registry
(2006–2013) from 7 centers in Italy reporting on
21 aberrant right subclavian artery aneurysms
[1]. In their series, the main diameter of aberrant
right subclavian artery aneurysm was 4.2 cm.
Majority of the patients had hybrid intervention
(15), with single (n2) or bilateral (n12) subclavian to carotid artery transposition or bypass.
Ascending aorta to subclavian artery bypass was
performed in one patient. Perioperative death
occurred in two patients. Late death occurred in
one patient due to aberrant right subclavian artery
aneurysm-esophageal stula [1]. Wooster et al.
reported hybrid repair in ten patients undergoing
management of aberrant right subclavian artery
aneurysm [2]. All ten patients required revascularization or exclusion of bilateral subclavian
arteries, to enable more than 20 mm proximal
aortic xation zone distal to the common carotid
artery for the endograft [2].
Invited Commentary
fromHimanshu J.Patel, MD
(TEVAR). Our center described a shifting paradigm from open to endovascular repair over the
course of two decades of experience [3]. While
elective cases can be addressed with a systematic
approach to subclavian artery revascularization,
those presenting with rupture present with a
more difcult dilemma. In our experience, the
conguration of the aortic arch in patients with
KD is often “Gothic” and the relative location of
the site of rupture at the origin of KD often
requires bilateral subclavian artery coverage to
achieve adequate proximal landing zone and prevent the “bird-beaking” phenomenon seen in the
tight Gothic arch.
There are several options potentially available
to address this dilemma. The rst option of simply covering the necessary branches has potential
for increased risks of stroke and in the instance of
extended descending aorta coverage, spinal cord
ischemia. The second option in the current era
could involve a snorkel or periscope option for at
least one of the arch vessels, but this has the
potential to promote endoleaks and the ongoing
risk for mortality from subsequent rupture. In my
opinion, the best option is yet to come, namely,
the use of branched endovascular aortic repair in
this setting. Until stent graft technology evolves
to allow for this option, we will continue to be at
the mercy of the underlying anatomy.
The Ruptured Kommerell’s Diverticulum
The treatment of a Kommerell’s diverticulum
(KD) has shifted considerably since the introduction of thoracic endovascular aortic repair
References
1. Verzini F, Isernia G, Simonte G, DeRango P, et al.
Results of aberrant right subclavian artery aneurysm
repair. J Vasc Surg. 2015;62:343–50.
References
345
2. Wooster M, Back M, Sutzko D, Gaeto H, etal. A tenyear experience using a hybrid endovascular approach
to treat aberrant subclavian artery aneurysm. Ann Vasc
Surg. 2018;46:60–4.
3. Van Bogerijen GH, Patel HJ, Eliason JL, et al.
Evolution in the management of aberrant subclavian
arteries and the related Kommerell Diverticulum. Ann
Thorac Surg. 2015;100:47–53.