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Primary Aortic Intimal Sarcoma Of The Visceral Aorta With Embolization: Endovascular Treatment For Palliation
Laura Holder, Lauren Gammel, Neelima Katragunta.
University of Tennessee Health Science Center-Chattanooga, Chattanooga, TN, USA.
DEMOGRAPHICS: 63-year-old male with morbid obesity, COPD, atrial fibrillation on Pradaxa, CAD, and severe deconditioning.
HISTORY: Patient presented with epigastric pain, nausea, vomiting and peritonitis on exam concerning for mesenteric ischemia. CTA revealed pulmonary nodules concerning for metastatic malignancy of uncertain origin as well as a large thrombus in the descending thoracic and visceral aorta with extension into the celiac artery with complete occlusion and evidence of embolization to the branches of the SMA (Figure A).
PLAN: Given the patient's extensive risk factors for open surgery, he was started on a heparin infusion and taken urgently for percutaneous thrombectomy using Penumbra device.
We removed the bulk of the lesion which on gross examination was a thick, tan-colored material concerning for a friable mass of the aortic wall with ongoing embolization potential. Therefore, the remainder of this lesion was covered with an aortic stent graft requiring coverage of the celiac artery. We then preserved the celiac artery using laser in-situ fenestration of the celiac origin through the aortic stent graft with placement of a covered stent in it. Final angiography demonstrated excellent positioning of the stent graft in the descending thoracic aorta up to the origin of the SMA as well as patent celiac, renal and iliac vessels (Figure C). The patient had dramatic resolution of his abdominal pain. We sent the material obtained with Penumbra for pathology which revealed it to be aortic intimal sarcoma for which chemotherapy was initiated. One month follow-up imaging revealed no endo-leak with patent celiac artery and SMA (Figure D).
DISCUSSION: Aortic intimal sarcomas (AIS) are rare primary vascular malignancies with less than 200 total cases reported in literature. These aggressive tumors often present with embolic complications requiring urgent intervention. Management of AIS depends on the extent of tumor involvement, presence of metastatic disease, and the patient’s clinical status. Treatments range from radical resection in surgically fit patients to variations of palliative surgery, including endarterectomy, bypass and endovascular stent placement. We present a minimally-invasive, palliative treatment option for AIS causing mesenteric ischemia in a patient with prohibitive surgical risk and possible metastatic disease.
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