Table of Contents    
CASE REPORT
Year : 2018  |  Volume : 9  |  Issue : 2  |  Page : 291-293  

Thoracic endovascular aneurysm repair for coarctation of the aorta with dissecting aortic aneurysm: A rarity


Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India

Date of Web Publication20-Jun-2018

Correspondence Address:
H S Natraj Setty
#493, 4th Cross, 7th Main, J.P. Nagar 3rd Phase, Bengaluru - 560 069, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsbm.JNSBM_152_17

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   Abstract 

Endovascular procedures aim to reduce the morbidity and mortality. Repair is indicated for aneurysms that are the source of pain and tenderness, which may indicate an impending rupture. The options for repair include traditional open aortic surgery or endovascular repair. Endograft has been used in patients with aortic dissection, noting the extremely complex nature of open surgical repair in these patients, while the results have been excellent. Aneurysm formation is a significant complication after therapy for Coarctation of aorta (CoA). Aneurysms develop after surgical as well as transcatheter repair procedures of CoA. We report a rare case of coarctation of the aorta with dissecting aortic aneurysm who presented with sudden onset of chest pain radiating to back and dyspnea for 3 days. He successfully underwent balloon dilatation of coarctation segment followed by aortic stent-graft implantation. Uneventful during procedure prompts recovery on follow-up.

Keywords: Aneurysm, coarctation of the aorta, endovascular repair


How to cite this article:
Reddy B, Natraj Setty H S, Srinivas B C, Shankar S, Kumar V, Sathish K, Mahadevaswamy B, Krishna M, Manjunath C N. Thoracic endovascular aneurysm repair for coarctation of the aorta with dissecting aortic aneurysm: A rarity. J Nat Sc Biol Med 2018;9:291-3

How to cite this URL:
Reddy B, Natraj Setty H S, Srinivas B C, Shankar S, Kumar V, Sathish K, Mahadevaswamy B, Krishna M, Manjunath C N. Thoracic endovascular aneurysm repair for coarctation of the aorta with dissecting aortic aneurysm: A rarity. J Nat Sc Biol Med [serial online] 2018 [cited 2018 Dec 12];9:291-3. Available from: http://www.jnsbm.org/text.asp?2018/9/2/291/234696


   Introduction Top


The incidence of spontaneous dissection in coarctation of the aorta is 0.7%. The incidence of dissection of the aorta after balloon dilatation of coarctation is 17%. Aneurysm formation is a significant complication after therapy for Coarctation of aorta (CoA). Aneurysms develop after surgical as well as transcatheter repair procedures of CoA. The reported prevalence of aneurysms after surgical repair of CoA is between 11% and 24%.[1] The incidence is reported to increase with advancing interval after surgical or transcatheter therapy.[2] Aneurysm development occurs independent of the surgical technique and has now been described after nearly every technique, including resection and end-to-end anastomosis, subclavian patch repair, and synthetic onlay patch repair.[3] Aortic replacements using synthetic vascular grafts have historically been the primary options for treatment of aortic aneurysms, thoracic endovascular aneurysm repair (TEVAR) as the principal minimally invasive alternative to open surgery.


   Case Report Top


A 31-year-old male patient presented with sudden onset of chest pain radiating to back and dyspnea (NYHA class II) for 3 days. On examination, pulse 90/m, B/L lower limb, and femoral pulses On examination, pulse 90/m, bilateral lower limb and femoral pulses are absent. At presentation, right upper limb 190/110 mm/Hg, left upper limb 170/100 mm/Hg, right lower limb 110/90 mm/Hg, left lower limb 112/90 mm/Hg. The routine investigation was normal. VDRL, HIV, and connective tissue profile were normal. Chest X-ray revealed mild cardiomegaly. Electrocardiography revealed left ventricular (LV) hypertrophy. Two-dimensional Echocardiography apical four-chamber view shows concentric LV hypertrophy, LV ejection fraction 60%, postsubclavian coarctation of the aorta gradient 80 mm/Hg, and aneurysm of descending thoracic aorta with dissection flap. CT aortogram revealed postsubclavian coarctation of the aorta and aneurysm of a poststenotic segment of descending aorta [Figure 1]. Dissection of the aorta in the poststenotic segment, the patient underwent balloon dilatation of coarctation segment followed by aortic stent-graft implantation to exclude the dissecting aortic aneurysm. Predilatation of coarctation segment was done with 14 mm × 40 mm Atlas balloon [Figure 2]a. Marker pigtail was used to take measurements; Valiant Captivia stent graft 30 × 30–150 cm was deployed distal left common carotid artery jailing the left subclavian artery. Postdilatation was done with 46 mm × 40 mm Reliant balloon [Figure 2]b. Following postprocedure, he continued to have back pain and then he underwent that aortogram revealed endovascular leak type 2 from left subclavian and branch of thyrocervical trunk. Subclavian artery closed with patent ductus arteriosus (PDA) device and endoleak type B was treated appropriately [Figure 3]a and [Figure 3]b. The patient improved symptomatically and is in 3-month follow-up, BP right upper limb 130/85 mm/Hg, right lower limb 140/85 mm/Hg on medications with ACEI, beta-blockers, and aspirin.
Figure 1: Computed tomography aortogram showing postsubclavian coarctation of the aorta. Aneurysm of poststenotic segment of descending aorta. Dissection of the aorta in poststenotic segment

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Figure 2: (a) Aortogram showing percutaneous transluminal angioplasty of coarctation with Atlas balloon. (b) Aortogram showing Valiant Captivia stent graft 30 mm × 150 mm deployed

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Figure 3: (a) Aortogram showing subclavian artery closed with patent ductus arteriosus device. (b) Computed tomography aortogram showing patent graft

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   Discussion Top


Thoracic endovascular aneurysm repair (TEVAR) is an emerging treatment modality, which has been rapidly embraced by clinicians treating thoracic aortic disease.[4] Thoracic endovascular aneurysm repair (TEVAR) has become the preferred approach for the treatment of thoracic aortic pathology. Initially utilized in the treatment of aortic aneurysmal disease, TEVAR indications have expanded to include treatment of type B aortic dissection with malperfusion or rupture, traumatic aortic transection, and penetrating aortic ulcer. Numerous studies suggest that TEVAR is associated with decreased morbidity compared with open repair.[5] Since the approval of the first thoracic endograft in 2005, thoracic endovascular aneurysm repair (TEVAR) has quickly become the treatment of choice for elective thoracic aortic aneurysm repair. The use of TEVAR has resulted in a decrease in both operative mortality and morbidity for patients with a wide variety of aortic pathologies. In addition, hospital length of stay is usually less following TEVAR. Appropriate inventories of endograft, as well as the full-time availability of a hybrid endovascular suite and team, are required.[6] Currently, thoracic endovascular aortic repair is the first treatment of choice in patients with aneurysms of the descending thoracic aorta, depending on the condition of the patient, demographic factors, and suitable anatomy for stent-graft deployment.[7] Device delivery is also challenging since adequate access is required to accommodate the diameter of those devices.[8] Management of endoleak at the time of the procedure: Type I: Endoleak at the proximal or distal seal zones is usually managed by additional ballooning or by placement of an extension graft.[9] Type II: Retrograde flow from the intercostal arteries can usually be managed conservatively with follow-up imaging to ensure that the aneurysm sac does not continue to enlarge. Type III: Junctional endoleak is usually related to inadequate overlap between components. Management consists of relining of the junction with stent grafts to bridge the defect. Type IV: Leak due to graft porosity causes Type IV endoleak. This typically resolves once the procedural anticoagulation wears off.[10]


   Conclusion Top


TEVAR has become the preferred approach for patients with thoracic aortic pathology and anatomy amenable to endograft placement. Adequate seal zones, careful preoperative planning, and proper device sizing are critical to obtain a good result and limit complications. It is worth mentioning that all patients with CoA should undergo an integrated imaging assessment of the aortic arch and the ascending and descending aorta before and after coarctation stenting. The use of computed tomography or magnetic resonance imaging along with angiography plays a key role in assessing this aortic arch anomaly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Bromberg BI, Beekman RH, Rocchini AP, Snider AR, Bank ER, Heidelberger K, et al. Aortic aneurysm after patch aortoplasty repair of coarctation: A prospective analysis of prevalence, screening tests and risks. J Am Coll Cardiol 1989;14:734-41.  Back to cited text no. 1
    
2.
Ovaert C, Benson LN, Nykanen D, Freedom RM. Transcatheter treatment of coarctation of the aorta: A review. Pediatr Cardiol 1998;19:27-44.  Back to cited text no. 2
    
3.
Knyshov GV, Sitar LL, Glagola MD, Atamanyuk MY. Aortic aneurysms at the site of the repair of coarctation of the aorta: A review of 48 patients. Ann Thorac Surg 1996;61:935-9.  Back to cited text no. 3
    
4.
Nienaber CA, Fattori R, Lund G, Dieckmann C, Wolf W, von Kodolitsch Y, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999;340:1539-45.  Back to cited text no. 4
    
5.
Matsumura JS, Cambria RP, Dake MD, Moore RD, Svensson LG, Snyder S, et al. International controlled clinical trial of thoracic endovascular aneurysm repair with the zenith TX2 endovascular graft: 1-year results. J Vasc Surg 2008;47:247-57.  Back to cited text no. 5
    
6.
Mitchell ME, Rushton FW Jr., Boland AB, Byrd TC, Baldwin ZK. Emergency procedures on the descending thoracic aorta in the endovascular era. J Vasc Surg 2011;54:1298-302.  Back to cited text no. 6
    
7.
Brunkwall S, Ahmad W, Mylonas S, Sharkawy M, Wippermann J, Brunkwall J, et al. The ascending aorta as an exit site for a through-and-through wire in TEVAR. J Endovasc Ther 2015;22:934-7.  Back to cited text no. 7
    
8.
Saouti N, Vos JA, van de Heuvel D, Morshuis WJ, Heijmen RH. Thoracic aorta stent grafting through transapical access. Ann Vasc Surg 2015;29:362.e5-9.  Back to cited text no. 8
    
9.
Piffaretti G, Mariscalco G, Tozzi M, Bruno VD, Sala A, Castelli P, et al. Acute iatrogenic type A aortic dissection following thoracic aortic endografting. J Vasc Surg 2010;51:993-9.  Back to cited text no. 9
    
10.
Wang GJ, Jackson BM, Woo EY, Bavaria JE, Desai ND, Pochettino A, et al. ''Relining'' of thoracic aortic stent grafts for patients presenting with rupture/impending rupture. Vasc Endovascular Surg 2011;45:438-41.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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