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Stafforini NA, Saldana-Ruiz N, DeRoo S, Schwarze U, Sweet MP, Zettervall SL. Multidisciplinary hybrid approach to management of a thoracoabdominal aneurysm in a patient with both Loeys-Dietz and vascular Ehlers-Danlos syndrome. J Vasc Surg Cases Innov Tech 2024; 10:101519. [PMID: 38982994 PMCID: PMC11231742 DOI: 10.1016/j.jvscit.2024.101519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/22/2024] [Indexed: 07/11/2024] Open
Abstract
Loeys-Dietz syndrome and vascular Ehlers-Danlos syndrome are genetic aortopathies that result from abnormal collagen matrix formation associated with vascular complications and early death. Identification of simultaneous COL3A1 and SMAD3 mutations as well as subsequent open and endovascular repair have not been reported. We present a case of a staged complete aortic replacement in a patient with a 7-cm aneurysm of his aortic arch and confirmed genetic mutations for Loeys-Dietz syndrome and vascular Ehlers-Danlos syndrome. This case highlights that, despite increased operative risk, successful staged repair of the entire aorta can be achieved in a patient with multiple severe genetic aortopathies.
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Affiliation(s)
- Nicolas A Stafforini
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Nallely Saldana-Ruiz
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Scott DeRoo
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Ulrike Schwarze
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
| | - Matthew P Sweet
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Sara L Zettervall
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
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Akutsu K, Ozaki K, Oshima S, Sakurai S, Hirokami T, Hirai Y, Okiyama M, Kishinami G, Ishiko K, Yamaguchi K, Yamamoto S. Successful redo open thoracoabdominal aortic aneurysm surgery in a patient with vascular Ehlers-Danlos syndrome: A case report. J Cardiol Cases 2024; 30:16-19. [PMID: 39007042 PMCID: PMC11245757 DOI: 10.1016/j.jccase.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 01/16/2024] [Accepted: 03/05/2024] [Indexed: 07/16/2024] Open
Abstract
We report a case of a 63-year-old woman diagnosed with vascular Ehlers-Danlos syndrome (vEDS) who survived two prophylactic surgeries for the dilatation of a thoracoabdominal aortic aneurysm. She initially developed acute type B aortic dissection at the age of 44 years. Five years later, her dissected descending aorta was enlarged to 54 mm; thus, the descending aorta was replaced as the first surgery. Fortunately, the intra- and post-operative courses were uneventful. Fourteen years post her first surgery, the dissected thoracoabdominal aorta distal to the graft expanded to 53 mm; however, no anastomotic leakage was observed. Genetic testing revealed a COL3A1 abnormality, confirming the diagnosis of vEDS. Thoracoabdominal aorta replacement using deep hypothermia circulatory arrest was performed because of the high risk of aortic aneurysm rupture. The second surgery was performed without complications, and no complications were observed 13 months post-surgery. The major reason for a successful surgery in this patient was the relatively low vascular fragility associated with vEDS. This case demonstrates that there may be considerable individual differences in vascular fragility in patients with vEDS. Thus, surgical repair, along with endovascular therapy, might still be a beneficial option for patients with vEDS having large aortic aneurysms and a high risk of rupture. Learning objective Prophylactic surgery for vascular lesions in Ehlers-Danlos syndrome (vEDS) is generally not recommended because of its high vascular fragility. However, if a patient with vEDS has an aortic aneurysm that is at a very high risk of rupture, aggressive treatment is a plausible option as there may be considerable individual differences in vascular fragility among patients with vEDS.
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Affiliation(s)
- Koichi Akutsu
- Department of Aortic Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Kensuke Ozaki
- Department of Aortic Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Susumu Oshima
- Department of Aortic Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Shigeru Sakurai
- Department of Aortic Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Tomohiro Hirokami
- Department of Aortic Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Yuki Hirai
- Department of Aortic Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Makoto Okiyama
- Department of Aortic Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Goro Kishinami
- Department of Aortic Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Kazumasa Ishiko
- Department of Aortic Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Ko Yamaguchi
- Department of Aortic Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Shin Yamamoto
- Department of Aortic Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
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Chen Y, Bashir M, Guo J, Piffaretti G, Jubouri M, D'Oria M. Expert-Based Narrative Review on Contemporary Use of an Off-The-Shelf Multibranched Endograft for Endovascular Treatment of Thoracoabdominal Aortic Aneurysms: Device Design, Anatomical Suitability, Technical Tips, Perioperative Care, Clinical Applications, and Real-World Experience. Ann Vasc Surg 2024; 108:98-111. [PMID: 38942377 DOI: 10.1016/j.avsg.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/10/2024] [Accepted: 05/15/2024] [Indexed: 06/30/2024]
Abstract
Advanced endovascular techniques, such as fenestrated stent grafts, are nowadays available that permit minimally invasive treatment of complex abdominal aortic aneurysms. However, thoracoabdominal aortic aneurysm patients have anatomic limitations to fenestrated stent-grafts given a large lumen, that is, the gap between the endograft and the inner aortic wall. This has led to the development of branched endovascular aneurysm repair as the ideal option for such patients. The Zenith t-Branch multibranched endograft (Cook Medical, Bloomington, IN), which has been commercially available in Europe to treat thoracoabdominal aortic aneurysm since June 2012, represents a feasible off-the-shelf alternative for treatment of such pathologies, especially in the urgent setting, for patients who cannot wait the time required for manufacturing and delivery of custom-made endografts. The device's anatomical suitability should be considered, especially for female patients with smaller iliofemoral vessels. Several tips may help deal with particularly complex scenarios (such as, for instance, in case of narrow inner aortic lumens or when treating patients with failure of prior endovascular aneurysm repair), and a broad array of techniques and devices must be available to ensure technical and clinical success. Despite promising early outcomes, concerns remain particularly regarding the risk for spinal cord ischemia and further assessment of long-term durability is needed, including the rate of target vessel instability and need for secondary interventions. As the published evidence mainly comes from retrospective registries, it is likely that reported outcomes may suffer from an intrinsic bias as most procedures reported to date have been carried out at high-volume aortic centers. Nonetheless, with the never-ceasing adoption of new and refined techniques, outcomes are expected to ameliorate.
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Affiliation(s)
- Yonghui Chen
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China.
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health & Education Improvement Wales (HEIW), Cardiff, Wales, UK
| | - Jiayin Guo
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Matti Jubouri
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health & Education Improvement Wales (HEIW), Cardiff, Wales, UK
| | - Mario D'Oria
- Department of Vascular and Endovascular Surgery, Cardio-Thoraco-Vascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
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Shalhub S, Byers PH. Endovascular repair of a common iliac artery aneurysm with an iliac branch device in a patient with vascular Ehlers-Danlos syndrome due to a null COL3A1 variant. J Vasc Surg Cases Innov Tech 2023; 9:101192. [PMID: 37274436 PMCID: PMC10238461 DOI: 10.1016/j.jvscit.2023.101192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/30/2023] [Indexed: 06/06/2023] Open
Abstract
Endovascular repair is avoided in patients with connective tissues disorders due to concerns for stent graft migration and endoleaks. We describe a successful endovascular repair of a common iliac artery aneurysm with a bifurcated aortoiliac stent graft and iliac branch endoprosthesis in a patient with Vascular Ehlers-Danlos syndrome (VEDS) due to a null COL3A1 variant. This case demonstrates that the VEDS genotype is associated with tissue integrity, specifically, individuals with VEDS due to null/haploinsufficiency variants, and adds to our understanding of endovascular repair in this population.
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Affiliation(s)
- Sherene Shalhub
- Division of Vascular and Endovascular Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR
| | - Peter H. Byers
- Department of Pathology, University of Washington, Seattle, WA
- Department of Medicine (Medical Genetics), University of Washington, Seattle, WA
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Iatrogenic Distal Aortic Rupture in a Patient with Vascular Ehlers–Danlos Syndrome. J Vasc Surg Cases Innov Tech 2023; 9:101156. [PMID: 37125345 PMCID: PMC10140053 DOI: 10.1016/j.jvscit.2023.101156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/18/2023] [Indexed: 03/13/2023] Open
Abstract
Vascular Ehlers-Danlos syndrome is a rare inherited connective tissue disorder that can result in significant morbidity and mortality. This report details an iatrogenic aortic rupture during an endovascular approach in the management of critical limb ischemia in a 27-year-old woman who presented with acute onset of severe sensory deficit of the left leg. Conversion to open repair with a midline laparotomy and an aortic-left popliteal bypass was performed. In the endovascular era, we highlight that even minimally invasive therapeutic interventions can have devastating adverse events in patients with vascular Ehlers-Danlos syndrome.
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Spanos K, Kodolitsch Y, Detter NC, Panuccio G, Rohlffs F, Eleshra A, Kölbel T. Endovascular treatment of aortic aneurysms and dissections in patients with genetically triggered aortic diseases. Semin Vasc Surg 2022; 35:320-333. [DOI: 10.1053/j.semvascsurg.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/20/2022] [Accepted: 06/27/2022] [Indexed: 11/11/2022]
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