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(Circulation. 1999;99:E9.)
© 1999 American Heart Association, Inc.

Circulation Electronic Pages

Nonsurgical Abolition of Thoracic Aortic Aneurysm

Gunnar K. Lund, MD; Christoph Diekmann, MD; Christoph A. Nienaber, MD

From the Department of Internal Medicine, Division of Cardiology, and the Department of Radiology (C.D.), University Hospital Eppendorf, Hamburg, Germany.

Correspondence to Christoph A. Nienaber, MD, FACC, FESC, Department of Cardiology, University Hospital Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. E-mail nienaber{at}uke.uni-hamburg.de

A67-year-old woman presented with clinical evidence of expansion of an aortic aneurysm previously acquired after a deceleration trauma. The patient complained of frequently recurring interscapular and back pain and beginning hoarseness. In the differential diagnostic workup, pneumothorax and pulmonary embolism were excluded. The patient underwent MRI of the thoracic aorta and gadolinium-enhanced 3-dimensional MR angiography (MRA) that demonstrated morphological evidence of a fist-size intrathoracic aortic aneurysm (Figure 1A). Selective angiography excluded significant coronary artery disease and confirmed the diagnosis of a true aneurysm of the descending thoracic aorta (Figure 2A). Because dimensional evaluation of the aneurysm revealed a transverse diameter >5.0 cm and because recurrent episodes of back pain suggesting potential expansion were evident, elective interventional stent-graft placement was offered to the patient to exclude the aneurysm and stabilize the thoracic aorta. On the basis of the MRA, a custom-made stent graft was manufactured according to the dimensional requirements of the patient's aorta; the nitinol stent with Dacron cover was inserted under general anesthesia and under transesophageal guidance in the catheter laboratory via a transfemoral access. Intraprocedural transesophageal echocardiography confirmed the aneurysm (Figure 3A) and was extremely helpful for both exact positioning of the stent graft and documentation of complete exclusion of the aneurysm. Moreover, transesophageal echocardiography demonstrated echogenetic "smoke" as evidence of beginning thrombosis in the aneurysmatic sac (Figure 3B). Perfect stent placement was confirmed by repeat selective contrast angiography via a pigtail catheter in the left subclavian artery (Figure 2B). Recovery and clinical follow-up were uneventful, and MRA 10 days later confirmed persistent exclusion of the aneurysm and a perfectly reconstructed thoracic aorta (Figure 1B).

View larger version (133K): [in this window] [in a new window]   Figure 1. A, Three-dimensional MRA after injection of gadolinium-DTPA showing posttraumatic symptomatic aneurysm of descending thoracic aorta. Adjacent aortic tube appears normal. B, Morphology of thoracic aorta after exclusion (abolition) of fist-sized aneurysm by interventional placement of a customized stent graft (Dacron-covered self-expandable nitinol stent). Aorta is successfully reconstructed, and aneurysmal sac is thrombosed; stent struts are identified by artifacts of high signal intensity.

View larger version (66K): [in this window] [in a new window]   Figure 2. A, During implantation procedure, selective angiography of thoracic aorta via left subclavian access confirms dimension of aortic aneurysm. B, After stent graft was launched via femoral access, perfect placement of stent graft and complete exclusion of aneurysm are documented by a second contrast aortogram.

View larger version (54K): [in this window] [in a new window]   Figure 3. A, Intraprocedural transesophageal ultrasound demonstrates thoracic aneurysm in long-axis view before stent-graft placement. B, Exact positioning of stent graft is confirmed, with complete abolition of aneurysm and beginning thrombosis in aneurysmal sac, as suggested by echogenic "smoke" (X).

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Lund, G. K. Articles by Nienaber, C. A. Search for Related Content PubMed PubMed Citation Articles by Lund, G. K. Articles by Nienaber, C. A. Related Collections Catheter-based coronary interventions: stents Echocardiography