A
Shah, D Appleton1,C Cousins1 and JR Boyle
Department
of Vascular Surgery and Interventional Radiology1,
Box 201, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 2QQ
Corresponding
Author
Dr
Jonathan Boyle
Addenbrookes
Hospital
Email:jonathan.boyle@addenbrookes.nhs.uk
Introduction
We
present the case of an 80-year-old man who presented with a ruptured
pseudoaneurysm of the thoracic aorta. Endovascular repair was performed urgently
6 days after his presentation following a period of considerable delay due to
both diagnostic delays and a lack of awareness of the recent advances in the
management of thoracic aortic pathology.
CASE
REPORT
An
eighty year old man with a history of hypertension and mild chronic renal
impairment presented to the emergency department of a peripheral unit with a
sudden onset of pain in his chest and right hypochondrium radiating to his right
scapula and associated with nausea and sweating. A chest roentogram showed a
widened mediastinal silhouette and clear lung fields. Serial ECGs and cardiac
enzymes were normal and the haemoglobin was 15.9g/dl.
The
patient was managed initially conservatively, however four days later without a
diagnosis and in the face of ongoing symptoms of severe pain a CT revealed a
ruptured pseudoaneurysm of the mid portion of the descending thoracic aorta (Figure
1). The following day he was referred to the tertiary vascular unit. He was
subsequently transferred as an emergency to our institution where on arrival he
was relatively hypotensive and his haemoglobin had fallen to 10g/dl.
He underwent an urgent endovascular repair of his pseudoaneurysm using a
TAG-Gore (40mm x 20cm) thoracic endograft (WL Gore, Flagstaff, AZ, USA). He
spent one day postoperatively on the intensive care unit before transfer to the
ward. A subsequent CT scan demonstrated good stent graft placement and aneurysm
seal (Figure 2). He was subsequently discharged eight days later and remains
well at six months follow-up.
DISCUSSION
Endovascular
repair of thoracic aortic aneurysm pathology, both acute and chronic, is one of
the most recent technological advancements in vascular surgery.1 This
less-invasive approach has the potential to reduce the morbidity and mortality
associated with the traditional open operative repair of TAAs (thoracic aortic
aneurysm).1 In addition, high-risk patients who would not be
considered for open repair and would not be treated may now be candidates for
this minimally invasive procedure.1 Although, a relatively new
technique it has shown such astounding success that it has already proved itself
as a key intervention tool.2 Gore’s non-randomized pivotal study of
elective thoracic aneurysms compared endovascular repair using the TAG device
(n=140) with open surgery (n=94) in 17 US institutions, the TAG group was
associated with reduced aneurysm-related deaths, fewer major adverse events
(e.g., bleeding, haematoma, renal failure), a reduced 30-day mortality, shorter
intensive care stay and hospital stay, less peri-operative blood loss and
earlier return to normal daily activities compared to the surgical group.3
NICE has also examined endovascular stent-graft placement in TAAs and has
produced provisional recommendations, which state that it is a suitable
alternative to surgery in properly selected patients.4 In its
systematic review of the published evidence it reports that the overall success
rate was 93% over 18 studies and the rate of conversion to open repair was
between 0 and 7%.5
The
rapid development of these techniques has been embraced by the vascular
community, however acute thoracic aortic pathology can present to a wide variety
of medical specialists. This case highlights the importance of not only
expeditious diagnosis but also up to date knowledge of the treatment options
available for the ruptured thoracic aorta. The patient was not a candidate for
open thoracic aortic surgery but did extremely well following endovascular
repair.
The
pseudoaneurysm in this case resulted from a penetrating ulcer of the thoracic
aorta. This presentation is not atypical and often patients who reach hospital
alive are found to have a contained rupture or slow leak as in this case.6
Patients who suffer significant aortic disruption into the chest will often not
survive to reach hospital.6
There
is no doubt that endovascular repair of the thoracic aorta will play an
increasing part in the management of TAA rupture, traumatic aortic transection
and complicated acute aortic dissection.2 It is important that the
vascular community educate their
colleagues about these
lifesaving techniques so that patients with thoracic aortic pathology who
previously may have been medically managed or palliated are transferred to an
appropriate unit for further assessment and treatment.
REFERENCES
1.
Aetna. Clinical Policy Bulletins. Endovascular Repair of Aortic
Aneurysms. December 23 2005. Available at: http://www.aetna.com/cpb/data/CPBA0651.html
2.
Katzen BT, Dake MD, MacLean AA, Wang DS. Endovascular repair of abdominal
and thoracic aortic aneurysms. Circulation. 2005;112(11):1663-75
3.
Makaroun MS, Dillavou ED, Kee ST, et al. Endovascular treatment of
thoracic aortic aneurysms: Results of the phase II multicenter trial of the GORE
TAG thoracic endoprosthesis. J Vasc Surg. 2005;41(1):1-9.
4.
National Institute for Clinical Excellence (NICE). Interventional
Procedure Consultation Document - endovascular stent-graft placement in thoracic
aortic
aneurysms and dissections. London, UK: NICE; 2005. Available at: http://www.nice.org.uk/page.aspx?o=244119
5.
National Institute for Clinical Excellence (NICE). A systematic review of
the recent evidence for the efficacy and safety relating to the use of
endovascular stent-graft (ESG) placement in the treatment of thoracic aortic
aneurysms. London, UK: NICE; 2004. Available at: http://www.nice.org.uk/page.aspx?o=244121
6. Eggebrecht H, Baumgart D, Schmermund A, et al. Penetrating atherosclerotic ulcer of the aorta: treatment by endovascular stent-graft placement. Curr Opin Cardiol 2003 Nov;18(6):431-5