Complex Hybrid Repair of a Ruptured Thoracoabdominal Aortic Aneurysm after Prior Endovascular Aortic Aneurysm Repair
Alisan Fathalizadeh, MD, MPH, Rashad Choudry, MD, Evan Deutsch, MD, Nadia Awad, MD.
Albert Einstein Medical Center, Philadelphia, PA, USA.
OBJECTIVES: Ruptured thoracoabdominal aortic aneurysms (TAAA) carry significant perioperative risk and pose treatment issues due to the complexity of the disease and repair. Endovascular interventions avoid the impact of aortic cross-clamping and visceral ischemic time in critical patients. We describe the successful repair of a large ruptured TAAA utilizing a hybrid repair technique employing thoracic endografts with concomitant mesenteric debranching in a patient with prior endovascular abdominal aortic aneurysm repair.
METHODS: A unique single case study demonstrating hybrid repair of ruptured TAAA was performed.
RESULTS: A 62-year-old female with a history of hypertension and prior endovascular repair of an abdominal aortic aneurysm, lost to follow up, presented to the emergency room in extremis. CT angiography demonstrated a ruptured 12cm extent II TAAA. She was taken emergently to the operating room. A 34mm Gore cTAG stent-graft was deployed distal to the left subclavian artery and a second aortic endograft was positioned, overlapping the prior abdominal stent graft. A Coda balloon was positioned in the proximal thoracic aorta for emergency control. Left-sided retroperitoneal exposure was performed, the visceral vessels were exposed, and a bifurcated 12mm to 6mm Dacron graft was anastomosed in an end-to-side fashion from the left external iliac artery to the SMA and celiac arteries maintaining constant visceral perfusion. A 6mm Gore Hybrid Vascular Graft was then used to bypass to the left renal artery to minimize renal ischemic time. The Coda balloon was removed, the pre-positioned thoracic endograft was deployed, and an additional thoracic endograft was placed between the two devices to ensure adequate overlap. No pulsatility was noted in the aneurysm sac, the visceral bypasses all had good pulses and good distal Doppler signals were present at the end of the case. The patient was taken to the intensive care unit in critical condition. She survived one week postoperatively with maintained renal and hepatic function, but was ultimately made comfort care due to poor neurologic recovery.
CONCLUSIONS: Ruptured TAAA poses significant treatment challenges. Hybrid approaches to repair can allow for successful exclusion of the aneurysm while avoiding the need for aortic cross-clamping and allowing for balloon-based aortic control. Mesenteric debranching with end-to-side anastomoses and novel hybrid bypass grafts can minimize visceral ischemic time.
Back to 2017 ePosters
