ENDOVASCULAR EXCLUSION OF A RUPTURED THORACOABDOMINAL ANEURYSM BY “OCTOPUS ENDOGRAFT”
Introduction: Involvement of the visceral arteries continues to limit the application of endovascular approaches. Open conventional repair is associated with higher morbimortality. With fenestrated and branched endografts, the total endovascular repair is effective, but these devices are not yet widely available and still require a period of customization. So they can’t be used in the majority of urgent cases. The authors present a successful case of exclusion of an aortic rupture with visceral arteries involvement.
Case Report: A 59-year-old man was admitted in our hospital by an thoracoabdominal aortic aneurysm rupture due to a infectious aortitis associated (fig. 1 e 2). The patient was hospitalized in a internal medicine department for bacterian aortic valve endocarditis (MSSA). As the patient needed urgent treatment and he had high anesthesic and surgical risk, he was submtitted to endovascular exclusion by an “octopus endograft”. Initially, a bifurcated endoprosthesis (Excluder® 35x14x140) was deployed in thoracic aortic (T5 level), followed by extension of contralateral leg with a tubular endograft (Excluder® 14x100mm). Afterwards, extension was performed for renal arteries and superior mesenteric by the other branch of the bifurcated endoprosthesis with covered stents (Viabahn®). In final angiography, the aneurysm was excluded and there were no endoleaks, with permeability of renal and mesenteric superior arteries. 1 week follow-up angioCT scan revealed a gutter type Ia endoleak and a type Ib endoleak in right renal artery with a significant filling of aneurysmal sac (fig. 3). Therefore, the patient was re-operated: distal extension of the right renal artery stent and gutter embolization with coils were performed. The final angiography and follow-up angioCT scan revealed no endoleaks and permeability of the revascularized visceral arteries (fig. 4). The patient was discharged with specific antibioteraphy to MSSA isolated in hemocultures (flucloxacilin). He was re-admitted 1 month later with chest pain. The angioCT revealed thoracic periprothesic collections that were drained guided by CT (MSSA). The patient did well, after drainage and antibiotheray, and was discharged again with antibiotic. He was re-admitted 4 months later with MRSA and Klebsiella septic shock . In imaging tests, as angioCT and PET, there were no signals of endoprothesis endoprosthesis and they revealed a spondylodiscitis of the thoracic vertebrae. Despite the broad spectrum of the antibiotherapy, the patient died after 2 weeks.
Conclusion: Despite of the final outcome, that was mainly related to original infectious disease, this case shows the feasibility of performing urgent endovascular exclusion of thoracoabdominal aneurysms without resource of fenestrated or branched endografts.
Aortic Aneurysms a Durable Treatment Option? Eur J Vasc Endovasc
Surg (2009) 37, 407e412
2. Sorelius K, Mani K, Bjork M et al. Endovascular repair of mycotic
aortic aneurysms. J Vasc Surg 2009; 50:269–74.
3. Jonker F, Verhagen H,Lin P et al. Outcomes of endovascular repair
of ruptured descending thoracic aortic aneurysms. Circulation
4. Giles K, Schermerhorn M, O’Malley A et al. Risk prediction for
perioperative mortality of endovascular vs open repair of abdominal
aortic aneurysms using the Medicare population. J Vasc
5. Ricotta J, Tsilimparis N. Surgeon-modified fenestrated-branched
stent grafts to treat emergently ruptured and symptomatic
complex aortic aneurysms in high-risk patients. J Vasc Surg
6. Kasirajan K. Branched Grafts for Thoracoabdominal Aneurysms:
Off-Label Use of FDA-Approved Devices. J Endovascular Therapy
7. Haidar G, Hicks , Strosberg D et al. “In situ” endografting in the treatment
of arterial and graft infections. J Vasc Surg 2017; 65(6): 1824–29.
8. Silveira P, Galego G, Bortoluzzi C et al. Re: Branched Grafts for
Thoracoabdominal Aneurysms: Off-Label Use of FDA-Approved
Devices. J Endovasc Ther. 2012 Feb;19(1):130.
9. Razavi MD, Razavi MK. Stent-Graft Treatment of Mycotic Aneurysms:
A Review of the Current Literature. J Vasc Interv Radiol 2008;
10. Kan C, Lee H, Yang Y. Outcome after endovascular stent graft
treatment for mycotic aortic aneurysm: A systematic review.J
Vasc Surg 2007;46:906-12.
11. Soule M, Javerliat I, Rouanet A et al. Visceral Debranching and
Aortic Endoprosthesis for a Suspected Mycotic Pseudoaneurysm
of the Abdominal Aorta Involving Visceral Arteries. Ann Vasc Surg
2010; 24: 825.e13-825.e16