Endovascular stent-graft repair of complicated penetrating atherosclerotic ulcers of the descending thoracic aorta

Abstract

To report our initial experience with endovascular stent-graft repair of complicated penetrating atherosclerotic ulcers as an alternative to surgery in patients with increased risk of perioperative morbidity and mortality. During a 2-year period, eight patients with complicated penetrating atherosclerotic ulcers of the descending thoracic aorta were treated with the Gore Excluder stent-graft. Patients (mean age, 70.6 years) presented with two to five comorbid conditions causing an increased risk for surgical repair. In addition to painful events, three patients presented with severe hemoptysis, one patient with shortness of breath, and one patient with dysphagia. All patients underwent emergency computed tomography, and diagnosis of contained rupture was confirmed in five patients. Computed tomographic findings included one to three penetrating ulcers per patient (n = 4), pseudoaneurysms (n = 5), additional intramural hematomas (n = 4), mediastinal bleeding (n = 2), and hematothoraces (n = 4). Through an iliac or femoral access site, a total of 11 stent-grafts were implanted under general (n = 5), epidural (n = 2), or spinal (n = 1) anesthesia. Deployment of stent-grafts was successful in all patients, and all sites of hemorrhage were sealed. The intramural hematoma resolved completely in three cases, and two pseudoaneurysms decreased in size. Intentional occlusion of the origin of left subclavian artery with the stent-graft in one patient was tolerated without left arm or cerebral symptoms. One patient experienced permanent paraplegia immediately after endovascular repair. There were no deaths during the hospital stay (range, 7-35 days; mean, 14.5 days). One patient was lost to follow-up after hospital discharge. The clinical observation period for the remaining seven patients was 38 to 99 weeks (mean, 60 weeks). Endovascular stent-graft repair in complicated penetrating atherosclerotic ulcers is an alternative therapeutic option to conventional thoracotomy, especially in patients at high risk of increased morbidity and mortality perioperatively and postoperatively.