Endovascular Treatment for Primary Aortic Angiosarcoma to Relieve Thoracic Aortic Stenosis

Follow-up results of aortic arch cervical debranching performed with the help of a temporary crossover external carotid artery bypass for cerebral protection followed by endovascular thoracic aortic aneurysm repair

OBJECTIVES

Treating aortic arch aneurysms with conventional open surgical and endovascular stent graft procedures is challenging due to the complex anatomy of the arch and the arteries arising from it that nourish the brain. Cerebral protection is of the utmost importance during the treatment of thoracic aneurysms involving the aortic arch.

METHODS

Between May 2014 and November 2018, 7 patients with thoracic aortic aneurysms involving the aortic arch who underwent aortic arch cervical debranching with our technique were reviewed retrospectively. Because all the patients being considered for conventional surgical aortic arch replacement had serious comorbidities, they were selected to receive hybrid therapy. The mean age of the patients was 71.2 ± 9.4 years. One patient was a woman and 6 patients were men. One patient was given general anaesthesia; the remaining 6 patients had a regional block. A crossover temporary bypass was performed between the external carotid arteries with a 6-mm polytetrafluoroethylene graft for cerebral protection in all patients. Thoracic endovascular aortic repair (TEVAR) was successfully performed in all patients except 1 following debranching.

RESULTS

Neurological complications did not occur during the procedures. Patients were followed for a mean of 18.3 ± 4.9 months. One female patient died of exacerbating chronic obstructive pulmonary disease within the first follow-up year. Three other patients died: 1 died of natural causes; 1 died of pneumonia followed by multiorgan failure; and 1 died of myocardial infarction during the mid-term follow-up period. The remaining patients are still being followed and are event free.

CONCLUSIONS

Endovascular treatment of thoracic aortic diseases involving the aortic arch is facilitated when the aortic arch is debranched. Our cerebral protection method with a temporary crossover bypass between the external carotid arteries provides continuous pulsatile blood flow to the brain; hence, neurologically, it is a reliable procedure. The follow-up results of the patients who underwent aortic arch cervical debranching followed by TEVAR depended on their comorbidities.

Primary aortic sarcoma in arch and descending aorta: a case report and literature review

Aortic sarcoma is a rare entity. In this study, we report a case of a 56-year-old man with complaints of pain and numbness of bilateral lower extremities. An endovascular aortic repair was finally adopted to prevent recurrent embolic events. An endo-biopsy was performed and showed aortic sarcoma. Axillary bifemoral and femoro-femoral cross-over bypass surgeries were taken to supply blood to the lower extremities in the 6th month after the first operation. He finally passed away in the 37th month. Aortic sarcoma should be taken into consideration as one of the possible etiologies for massive thrombus in aorta. Palliative surgeries such as bypass, endovascular aortic repair can also be an alternative to treat aortic sarcoma.

Thoracic Endovascular Aortic Repair for Embolizing Total Occlusion of the Descending Aorta due to Aortic Sarcoma

Primary malignant tumors of the aorta are extremely rare, and the diagnosis is difficult from the clinical onset. Accordingly to the principles of cancer surgery, "en bloc" resection of the tumor-involved aorta and graft interposition is the gold standard, but it is still technically challenging and comorbidities may rule out some patients from an operative treatment. Thoracic endovascular aortic repair has been reported anecdotally, but it is an ease and rapid alternative in urgent circumstances and proved to be effective to relieve symptoms caused by these lesions. Unfortunately, no matter what is the type of histology or immunohistochemistry, or the type of treatment, the prognosis of aortic malignancies is very poor. Nevertheless, an operative treatment strategy which includes surgical resection and chemotherapy or radiation had long survival than patients treated with a single modality. We report a case of acute mesenteric syndrome caused by an occlusive and embolizing thrombus of the descending thoracic aorta caused by primary aortic sarcoma treated with thoracic endovascular aortic repair.