Successful Endovascular Treatment of a Ruptured Type I Thoracoabdominal Aneurysm … Twice

Abstract

Only a minority of vascular surgeons have personal experience on thoracoabdominal aneurysm (TAA) repair, and even less have performed surgery on these formidable lesions for rupture. Unsurprisingly, when open surgery was the only treatment option available, these impressive pathologies were frequently deemed inoperable and managed conservatively. Endovascular techniques brought new hope in these scenarios, but despite current advances, morbidity and mortality remain high, even in experienced centers. The authors present a rare case of a patient with a type I TAA, with chronic occlusion of the superior mesenteric artery (SMA) and celiac trunk (CT), and total visceral perfusion through the inferior mesenteric artery, who survived aneurysm rupture on 2 separate occasions. A 69-year-old man, with multiple known comorbidities such as coronary heart disease, chronic obstructive pulmonary disease, and stage 4 chronic kidney disease, presented with acute chest pain and dyspnea. Computed tomographic angiography (CTA) revealed a ruptured type I TAA, with extensive left hemothorax. Chronic occlusion of both the CT and SMA were also noted, with all visceral perfusion dependent on an extremely hypertrophic inferior mesenteric artery and associated abdominal collateralization. As the patient was in a predialysis condition, efforts to maintain renal patency were considered unfounded, and, based on this, 2 thoracic endoprosthesis were implanted, extending from the left subclavian artery to the visceral aorta, below the renal arteries. Proper aneurysm exclusion was obtained; the patient survived and was discharged 26days after admission. He was later observed at 6-month follow-up, where CTA confirmed aneurysm exclusion, with no endoleak or graft migration. After this observation, the patient did not comprise with the next appointed consultations and was deemed lost to follow-up. Five years later, the same patient was again admitted to our institution, with acute chest pain and dyspnea. CTA revealed new aneurysm rupture, secondary to an extensive type Ib endoleak due to total loss of distal seal. Significant mismatch between the implanted thoracic endografts and the healthy infrarenal aorta was noticeable (∼30mm vs 15mm). Distal seal was, therefore, reobtained through the implantation of an aortouni-iliac graft and iliac extension, extending from the previous grafts to the infrarenal aorta and landing immediately proximal to the inferior mesenteric artery. The intervention was eventless; the patient survived and was discharged 1month after admission. Control CTA confirmed aneurysm exclusion. TAA rupture is a dreadful condition, associated with high mortality rates. Visceral vessel preservation is the main limiting factor for technical success. The importance of proper follow-up should always be emphasized.