Exclusion of an Aneurysmal Segment of the Thoracic Aorta With Covered Stents
The patient was an 80-year-old woman who presented to her local hospital with left-sided chest pain. A CT scan of the thorax demonstrated an aneurysm of the middle third of the thoracic aorta with a diameter of 9.5 cm. The patient presented a significant operative risk, with marked comorbidity, including chronic venous ulceration and poor respiratory function secondary to lifelong smoking. Initial surgical opinion maintained that the risks of operative intervention were too high to justify the performance of surgical repair. She was referred to a cardiothoracic surgeon at this institution for a second opinion.
3D contrast-enhanced MR angiography performed at the Royal Brompton (image, Pre-stenting) confirmed the existence of a saccular aneurysm of the descending thoracic aorta. The aneurysm began shortly after the origin of the left subclavian artery and measured 9.2 cm in diameter and 12 cm in length. Mural thrombus was noted along the left and posterior walls of the diseased segment. The paucity of contrast in the image presented was related to an acute angulation at the distal end of the aneurysmal portion.
The aneurysm was excluded with a covered stent. Under general anesthesia, the right femoral artery was exposed and cannulated with an angiographic catheter. Contrast images of the arch and descending aorta were acquired, and patency of the femoral and iliac system was confirmed. A 31×150-mm stent device with a GoreTex coating (WL Gore Thoracic Excluder Endoprosthesis PB-31-15-00) was inserted via a 22F introducer and deployed. Contrast angiography after deployment revealed that the lower portion of the aneurysmal segment had not been excluded, and an additional shorter device (31×70 mm) was deployed. Postimplantation dilation was performed with a perfusion balloon system (WL Gore PD-26-31-10). The femoral arteriotomy was closed with a vein patch, and the patient made an uncomplicated recovery.
A follow-up MR angiogram performed 3 days after stent implantation (image, Post-stenting) showed the stent to be patent along its length and 32 mm in diameter. The aortic lumen outside the stent graft was largely thrombosed. An area of signal enhancement around the distal third of the stented portion was compatible with a small leak at the junction of the 2 stent devices. A further follow-up scan performed 1 month after the procedure demonstrated that this communication with the false lumen had closed.
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 the Circulation editorial office, St Luke’s Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
- Copyright © 2000 by American Heart Association