IVUS guidance of thoracic and complex abdominal aortic aneurysm stent-graft repairs using an intracardiac echocardiography probe: preliminary report

PURPOSE

To report our learning experience using an intracardiac echocardiography (ICE) probe to guide endovascular aortic procedures.

METHODS

Between November 1999 and July 2001, 17 patients (12 men; mean age 73.1+/-2.3 years) underwent endovascular repair of 9 thoracic, 6 complex abdominal, and 2 thoracoabdominal aortic aneurysms. The most suitable dimensions and configuration of the stent-graft were based on preoperative computed tomographic (CTA) or magnetic resonance (MRA) angiography. Intraoperative intravascular ultrasound (IVUS) imaging was obtained using a 9-F, 9-MHz ICE probe, 110 cm in length, inserted through a 10-F, 55 degrees precurved long polyethylene sheath.

RESULTS

The endografts were deployed as planned by CTA or MRA. Before stent-graft deployment, interrogation with the ICE probe visualized the aortic arch and descending thoracoabdominal aorta without position-related artefacts and identified the sites of stent-graft fixation. After stent-graft deployment, visualization with the ICE probe detected the need for additional procedures in 8 patients, including 2 incompletely expanded thoracic grafts, which were treated with adjunctive balloon angioplasty. In 1 patient, ICE probe interrogation determined that the lesion was inappropriate for endovascular exclusion.

CONCLUSIONS

ICE probe interrogation provides accurate information on the anatomy of thoracic and abdominal aortic aneurysms and allows rapid identification of attachment sites and stent-graft characteristics. It might be considered as a valid imaging modality for monitoring all phases of endovascular procedures.

Emergency stent-graft repair of a ruptured hepatic artery secondary to local postoperative peritonitis

PURPOSE

To describe the use of a stent-graft for emergent repair of life-threatening hepatic artery hemorrhage.

METHODS AND RESULTS

A 57-year-old man with a 17-year history of myxoid liposarcoma underwent surgery for a recurrent abdominal mass. Multivisceral resection including a Kausch-Whipple procedure with an extended right hemicolectomy was performed. Three weeks later, an episode of gastrointestinal bleeding prompted surgical repair of the hepatic artery, which had been eroded by infection due to a leaking bilioenteric anastomosis. After 3 weeks of programmed abdominal lavage, bleeding recurred. Angiography documented another rupture of the proximal hepatic artery. After an unsuccessful attempt at coil embolization, a Hemobahn stent-graft was implanted percutaneously during simultaneous cardiopulmonary resuscitation. Hemostasis was secured, and the patient recovered. Over the 10-month follow-up, no bleeding or infection has been observed at the site of the repair, and flow through the hepatic artery endograft remains satisfactory.

CONCLUSIONS

Percutaneous stent-graft placement can be employed for emergent treatment of visceral artery rupture in patients at high risk for conventional surgical repair.

Repair of mycotic paravisceral aneurysm with a fenestrated stent-graft

PURPOSE

To report the successful endovascular repair of a mycotic paravisceral aneurysm using a fenestrated stent-graft.

METHODS AND RESULTS

A 55-year-old white female with a history of rheumatoid arthritis presented with an 8-cm paravisceral aneurysm secondary to pneumonia complicated by empyema. Intravascular ultrasound identified a defect in the aortic wall at the level of the celiac axis. Repair was accomplished with a fenestrated stent-graft that excluded the aneurysm and maintained flow to the celiac axis and superior mesenteric artery. Recovery was uneventful and the patient was discharged in 2 days. Six-month follow-up computed tomographic scanning confirmed aneurysm exclusion and flow to the celiac and superior mesenteric arteries. There was no evidence of graft infection. The patient died from a clinically diagnosed myocardial infarction 10 months after the stent-graft repair.

CONCLUSIONS

Fenestrated stent-graft repair may evolve into a useful technique for the treatment of mycotic paravisceral aneurysms.

Endovascular repair of an innominate artery false aneurysm following blunt trauma

PURPOSE

To describe a case of endovascular graft exclusion of an innominate artery pseudoaneurysm arising from blunt trauma.

METHODS AND RESULTS

A 21-year-old patient was admitted following a major road accident. Computed tomography (CT) and aortography on admission disclosed an isolated innominate artery pseudoaneurysm. The lesion was stable, so an elective endoluminal repair was undertaken once the patient was treated for his other injuries. The right carotid artery was exposed and controlled, and the aneurysm was excluded by transluminal implantation of a customized stent-graft consisting of predilated polytetrafluoroethylene graft material covering a balloon-expandable Palmaz stent. A CT scan at 1 month and duplex scans at 6-month intervals documented good stent-graft positioning and aneurysm exclusion over a period of 18 months.

CONCLUSIONS

This case illustrates the potential durability of endoluminal repair of innominate artery lesions and highlights the potential role of this minimally invasive alternative to surgery in these clinical situations.