Limits...
The modified chimney technique with a thoracic aortic stent graft to preserve the blood flow of the left common carotid artery for treating descending thoracic aortic aneurysm and dissection.

Lee KN, Lee HC, Park JS, Kim BW, Cha KS, Kim SP, Lee CW, Kim HK - Korean Circ J (2012)

Bottom Line: The main limitation is related to the anatomical difficulties when disease involves the aortic arch.A fenestrated, branched aortic stent graft and hybrid operation has been introduced to overcome this limitation, but it is a custom-made device and is time consuming to manufacture.Furthermore, these devices cannot be used in an emergency setting.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Pusan National University College of Medicine, Busan, Korea.

ABSTRACT
While thoracic endovascular aortic repair is an effective treatment option for descending thoracic aorta pathology, it does have limitations. The main limitation is related to the anatomical difficulties when disease involves the aortic arch. A fenestrated, branched aortic stent graft and hybrid operation has been introduced to overcome this limitation, but it is a custom-made device and is time consuming to manufacture. Furthermore, these devices cannot be used in an emergency setting. We report two patients with massive descending thoracic aortic aneurysm and ruptured aortic dissection very near the aortic arch who underwent a procedure which we named the modified chimney technique. The modified chimney technique can be used as a treatment option in such an emergency situation or as a rescue procedure when aortic pathology is involved near the supra-aortic vessels.

No MeSH data available.


Related in: MedlinePlus

CT showed a Stanford type B aortic dissection and intramural hematoma at the thoraco-abdominal aorta (A-D). An intimal flap was noted just distal from the left subclavian artery (white arrow in E and F). The intramural hematoma extended to the origin of the renal artery (C).
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Figure 1: CT showed a Stanford type B aortic dissection and intramural hematoma at the thoraco-abdominal aorta (A-D). An intimal flap was noted just distal from the left subclavian artery (white arrow in E and F). The intramural hematoma extended to the origin of the renal artery (C).

Mentions: A 49-year-old female experiencing untreated hypertension for several years presented with severe chest and back pain. A CT scan was performed and revealed an aortic dissection (Stanford type B) and an intimal flap was noted immediately distal from the origin of the left subclavian artery. After 4 days of medical management, her urine output decreased and both femoral pulses were weakened. Another CT scan was performed, showing that the aortic dissection had worsened and there was nearly total occlusion of the mid-aorta (Fig. 1). We recommended aortic repair operation, which the patient and her family refused. TEVAR was recommended as another treatment option to cover the intimal flap of the dissection. To acquire the proper proximal landing zone, her left subclavian artery and two thirds of the origin of the left common carotid artery would be covered by the stent graft. For the occluded left subclavian artery, revascularization can then be selectively considered in a staged approach if left arm pain, claudication and subclavian steal syndrome develop. The modified chimney technique was planned to preserve the blood flow of the left common carotid artery. The patient was taken to the cardiac catheterization laboratory and a left femoral arteriotomy was performed under general anesthesia. The 035 inch wire was placed in the ascending aorta and the left subclavian artery through the left radial artery approach. This wire is important to rescue the left carotid artery flow. If an aortic stent graft totally covers the left carotid artery or if it is difficult to select the left carotid artery with a catheter, then we can perform emergency balloon dilatation and place a chimney graft stent from the left subclavian artery to the aorta via this wire. The deployment of a 38×150 mm SEAL aortic stent graft (S&G Biotech, Seongnam, Korea) was performed so that the proximal part of the stent graft covered two thirds of the ostium of the left common carotid artery. After selection of the left common carotid artery using a 5 Fr Judkin right catheter (Cordis, Hialeah, FL, USA) through the gap between the stent graft and the left carotid artery, we passed a 035 inch Terumo wire (Terumo, Tokyo, Japan) into the left carotid artery through the right femoral artery and exchanged it with an Amplatz stiff wire. Then, an 8×60 mm SMART nitinol stent (Cordis, Hialeah, FL, USA) was deployed into the left common carotid artery. A final angiogram showed excellent results with good flow to both the thoracic aorta and the left common carotid artery. No endoleak was noted (Fig. 2). The occluded true lumen was re-expanded and the false lumen was not seen. The mean pressure gradient between the thoracic and abdominal aorta was decreased to 20 mm Hg from 90 mm Hg immediately after TEVAR (Fig. 2). After 18 months there has been no endoleak, restenosis of the stent in the left carotid artery or other complications.


The modified chimney technique with a thoracic aortic stent graft to preserve the blood flow of the left common carotid artery for treating descending thoracic aortic aneurysm and dissection.

Lee KN, Lee HC, Park JS, Kim BW, Cha KS, Kim SP, Lee CW, Kim HK - Korean Circ J (2012)

CT showed a Stanford type B aortic dissection and intramural hematoma at the thoraco-abdominal aorta (A-D). An intimal flap was noted just distal from the left subclavian artery (white arrow in E and F). The intramural hematoma extended to the origin of the renal artery (C).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3369971&req=5

Figure 1: CT showed a Stanford type B aortic dissection and intramural hematoma at the thoraco-abdominal aorta (A-D). An intimal flap was noted just distal from the left subclavian artery (white arrow in E and F). The intramural hematoma extended to the origin of the renal artery (C).
Mentions: A 49-year-old female experiencing untreated hypertension for several years presented with severe chest and back pain. A CT scan was performed and revealed an aortic dissection (Stanford type B) and an intimal flap was noted immediately distal from the origin of the left subclavian artery. After 4 days of medical management, her urine output decreased and both femoral pulses were weakened. Another CT scan was performed, showing that the aortic dissection had worsened and there was nearly total occlusion of the mid-aorta (Fig. 1). We recommended aortic repair operation, which the patient and her family refused. TEVAR was recommended as another treatment option to cover the intimal flap of the dissection. To acquire the proper proximal landing zone, her left subclavian artery and two thirds of the origin of the left common carotid artery would be covered by the stent graft. For the occluded left subclavian artery, revascularization can then be selectively considered in a staged approach if left arm pain, claudication and subclavian steal syndrome develop. The modified chimney technique was planned to preserve the blood flow of the left common carotid artery. The patient was taken to the cardiac catheterization laboratory and a left femoral arteriotomy was performed under general anesthesia. The 035 inch wire was placed in the ascending aorta and the left subclavian artery through the left radial artery approach. This wire is important to rescue the left carotid artery flow. If an aortic stent graft totally covers the left carotid artery or if it is difficult to select the left carotid artery with a catheter, then we can perform emergency balloon dilatation and place a chimney graft stent from the left subclavian artery to the aorta via this wire. The deployment of a 38×150 mm SEAL aortic stent graft (S&G Biotech, Seongnam, Korea) was performed so that the proximal part of the stent graft covered two thirds of the ostium of the left common carotid artery. After selection of the left common carotid artery using a 5 Fr Judkin right catheter (Cordis, Hialeah, FL, USA) through the gap between the stent graft and the left carotid artery, we passed a 035 inch Terumo wire (Terumo, Tokyo, Japan) into the left carotid artery through the right femoral artery and exchanged it with an Amplatz stiff wire. Then, an 8×60 mm SMART nitinol stent (Cordis, Hialeah, FL, USA) was deployed into the left common carotid artery. A final angiogram showed excellent results with good flow to both the thoracic aorta and the left common carotid artery. No endoleak was noted (Fig. 2). The occluded true lumen was re-expanded and the false lumen was not seen. The mean pressure gradient between the thoracic and abdominal aorta was decreased to 20 mm Hg from 90 mm Hg immediately after TEVAR (Fig. 2). After 18 months there has been no endoleak, restenosis of the stent in the left carotid artery or other complications.

Bottom Line: The main limitation is related to the anatomical difficulties when disease involves the aortic arch.A fenestrated, branched aortic stent graft and hybrid operation has been introduced to overcome this limitation, but it is a custom-made device and is time consuming to manufacture.Furthermore, these devices cannot be used in an emergency setting.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Pusan National University College of Medicine, Busan, Korea.

ABSTRACT
While thoracic endovascular aortic repair is an effective treatment option for descending thoracic aorta pathology, it does have limitations. The main limitation is related to the anatomical difficulties when disease involves the aortic arch. A fenestrated, branched aortic stent graft and hybrid operation has been introduced to overcome this limitation, but it is a custom-made device and is time consuming to manufacture. Furthermore, these devices cannot be used in an emergency setting. We report two patients with massive descending thoracic aortic aneurysm and ruptured aortic dissection very near the aortic arch who underwent a procedure which we named the modified chimney technique. The modified chimney technique can be used as a treatment option in such an emergency situation or as a rescue procedure when aortic pathology is involved near the supra-aortic vessels.

No MeSH data available.


Related in: MedlinePlus