Aorta
TAA

Branched stent-graft used for type IV thoracoabdominal aneurysm in abdominal aortic agenesis

This case report considers a 49-year-old women which presented a progressive large aneurysm of the type IV thoraco-abdominal aorta in a context of abdominal aortic agenesis.

In collaboration with:
C. Caradu, J. Pudzeis - Dept of Vascular Surgery, CHU Pellegrin, Bordeaux, France
M. Pernot, A. Aguettant d'Aubigny, L. Labrousse - Dept of Cardio-thoracic Surgery, CHU Haut-Lévêque, Bordeaux, France

Éric Ducasse
Éric Ducasse
Hospital Pellegrin - Bordeaux, France
Professor of vascular surgery

Professor of vascular surgery
Head of unit of vascular surgery CHU Bordeaux - France

Conflicts of interest:

Honoraria from: COOK Médical, Térumo-Vascutek, Siemens, GORE

Part I - Medical history
  • Active smoking
  • Arterial hypertension
  • Abdominal aortic agenesis
  • Solitary functioning right kidney
  • Left transfemoral amputation at 35 and right transtibial amputation at 37 in a context of arterial thrombosis
  • Pulmonary embolism at 18
  • Peripartum deep vein thrombosis
Progressive large aneurysm (67 mm) of the type IV thoraco-abdominal aorta (TAAA)
Medical history

Thrombophilia suspected

Part II : Treatment
  • Weight : 40kg
  • Height : 140cm (<165cm)
  • GFR : 74,6 ml/min

Custom-made triple-branched endovascular graft (Cook Medical) deployed from a trans-apical access

Custom-made triple-branched endovascular graft

Angiogram perioperative

Trans-apical access by anterior thoracotomy

  • Transoesophageal echocardiogram control
  • Hybrid suite with fusion imaging capabilities
  • Heparinization systemic
Trans-apical access by anterior thoracotomy

Stenting of the target vessels by right axillary artery

  • 8Fr introducer
  • Covered stents (COVERA­™ BD)

 

  • RRA: 7mm diameter
  • CT: 9mm diameter
  • SMA: 8mm diameter

ACT : 238-240 seconds

 

Post operative period

Total thrombosis of the stent-graft and mesenteric portal veinous system

  • Prosthetic bypass between ascending aorta and right hepatic, SMA and right renal arteries

Multiple complications

  • D+2 Haemostasis for haemorrhage, right colectomy and cholecystectomy
  • D+4 Making of an ileocolostomy, 60cm resection of necrotic bowel, evacuation of hematoma of the mesentery
  • Persistant thrombocytopenia (Platelets 7 g/l) of multi-factorial origin (peripheral consumption on multiple thromboses, splenomegaly on portal thrombosis, inflammation, spinal stupor)
  • Kidney failure KDIGO 3 dialysis
  • Grade E pancreatitis
  • Digestive bleeding (peristomial, gastric ulcers)
  • D+12 MOF and died

Discussion

Agenesis of the abdominal aorta and iliac arteries is an extremely rare congenital vascular anomaly, associated with various long-term morbidities.

To treat thoracoabdominal aortic aneurysm, open procedures are more complex and associated with high mortality and morbidity rates

In the presented case, the patient was evaluated in a multidisciplinary team. High risk of pelvic necrosis under ECC and under-recognized or misdiagnosed hemophilia contraindicated open repair. An endovascular repair was considered to be the optimal solution.

The absence of an adequate femoral or iliac access to deliver a branched or fenestrated endograft is usually considered an absolute contraindication for endovascular repair.

Alternative routes and dedicated stent-graft designs have been advocated.

  1. Transapical and axillary access to deploy standard straight thoracic stent-grafts has been previously demonstrated in patients with aorto-iliac occlusion
    Malik, K., Poletto, G., Zhao, Y., & Civilini, E. (2019). Unconventional Endovascular Access for Symptomatic Thoracic Aortic Ulcer with Infrarenal Aortic Occlusion—A Case Report. Annals of Vascular Surgery.
  2. Only one other case use of a custom-made triple- branched endovascular graft deployed from a transaxillary access to treat a aneurysm associated with pararenal aortic occlusion
  • Postoperative course was uneventful
    Bertoglio, L., Lopes, A. C., Rinaldi, E., Bossi, M., Berchiolli, R. N., Ferrari, M., & Chiesa, R. (2022). Transaxillary Tri-Branch Aortic Endovascular Graft Repair of Recurrent Thoracoabdominal Aneurysm With Pararenal Aortic Occlusion. Journal of Endovascular Therapy

Conclusion

The use of this custom-made tri-branched device, combined with the transapical access, allowed to treat this aneurysm through a less invasive approach, despite the unfortunate outcome.

Transapical and axillary access have allowed to extend the number of eligible patients to endovascular approach.

Further validation and longer follow-up times would be required to prove the effective durability of this visceral aortic stump

  • Post operative anticoagulation management more aggressive?

References