Abstract
Background
Aortic arch pathology is traditionally treated via open methods involving arch or hemiarch replacement. Advances in transcatheter endograft technology have provided a minimally invasive alternative in selected cases.
Case Summary
We herein describe the case of a 75-year-old man with an aortic arch aneurysm on the background of a previous coronary artery bypass graft involving a left internal mammary artery–to–left anterior descending artery (LIMA-LAD) graft, who was treated with a Bolton Relay custom scalloped stent graft.
Discussion
This case highlights the feasibility of endografts in the setting of a LIMA-LAD graft and the importance of detailed preoperative planning within a multidisciplinary approach.
Take-Home Message
Custom thoracic endovascular aortic repair is a safe alternative to open surgery in the treatment of aortic arch aneurysm in high-risk patients with a LIMA-LAD graft.
Key words: aortic aneurysm, endograft, cardiovascular surgery, thoracic endovascular aortic repair, transcatheter technology
Graphical Abstract
History of Presentation
A 75-year-old man was found to have an incidental 5.7-cm saccular aortic arch aneurysm after presentation to the local emergency department with syncope. This was in the context of having undergone coronary artery bypass graft involving a left internal mammary artery (LIMA)–to–left anterior descending artery (LAD) graft and saphenous vein graft (SVG)–to–right coronary artery (RCA) 6 years prior. He was discussed in a meeting of the complex aortic multidisciplinary team and was considered for open repair with or without revascularization versus thoracic endovascular aortic repair (TEVAR) and carotid-subclavian bypass, which was deemed too high risk in the context of a LIMA-LAD graft.
Take-Home Message
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•
Custom TEVAR is a safe alternative to open surgery in the treatment of aortic arch aneurysms in high-risk patients with a LIMA-LAD graft.
Past Medical History
Included in the patient's medical history was the coronary artery bypass graft ×2 (LIMA-LAD, SVG-RCA) as well as non–ST-segment elevation myocardial infarction with percutaneous coronary intervention to the SVG 6 years later, hypertension, paroxysmal atrial fibrillation, and type 2 diabetes mellitus.
Differential Diagnosis
The differential diagnosis included saccular pseudoaneurysm at the inferior aspect of the distal aortic arch.
Investigations
Computed tomography scan demonstrated a 5.9 × 5.7 × 5.2 cm saccular aneurysm arising from the distal aortic arch at the region of the ligamentum arteriosum (Figure 1) with contrast opacification of the central aneurysm. The remaining two-thirds of the sac was occupied by thrombus (Figure 2). The aneurysm also demonstrated mild localized mass effect with indentation of the superior aspect of the left main pulmonary artery. There was no contrast extravasation.
Figure 1.
Axial Computed Tomography Demonstrating a 5.9 × 5.7 × 5.2 cm Aneurysm of the Distal Aortic Arch
Figure 2.
Sagittal Computed Tomography Demonstrating the Full Extent of the Arch Aneurysm
(A) Two-thirds of the sac was occupied by thrombus. (B) Relationship to the left subclavian artery.
Management
A decision was made to proceed with TEVAR using a Bolton Relay custom scalloped thoracic stent graft to preserve the LIMA-LAD graft while ensuring a sufficient landing zone for a good seal (Figure 3). After bilateral femoral access, the device was inserted and deployed with a large scallop at the origin of the left subclavian artery (LSA) (Figure 4). The aneurysm at the inferior aspect of the distal aortic arch was excluded. There were no intraoperative complications, with a good technical result and no endoleak. Specifically, there were no new arrythmias or hemodynamic instabilities throughout the case. LIMA patency was confirmed via angiography after deployment.
Figure 3.
Bolton Relay Custom Scalloped Stent Graft
(A) Illustration of Bolton Relay custom scalloped stent graft. (B) Postdeployment illustration.1
Figure 4.
Sequential Deployment of Thoracic Endovascular Aortic Repair
The white line in (B) indicates the stent scallop.
Outcome and Follow-Up
Postoperatively, the patient had a single inpatient episode of fast atrial fibrillation, which was rate controlled with bisoprolol in the context of chronic atrial fibrillation, after which he was discharged on postoperative day 9. He was readmitted after a syncopal event, found to be due to a conversion pause between the atrial fibrillation and sinus rhythm. This led to a permanent pacemaker insertion to reduce the risk of further syncope-associated pauses. He was reviewed in clinic at 6 weeks postoperatively and had no further complications. A repeat computed tomography scan at 30 days (Figure 5) demonstrated satisfactory appearance of the thoracic stent graft, with normal opacification of the aortic arch branches and stable appearance of the arch aneurysm. There was no evidence of endoleak. Subsequent follow-up was arranged as per the standard TEVAR imaging surveillance pathway, with no special adjustment for the LIMA-LAD.
Figure 5.
Postoperative Computed Tomography Findings
(A) Postoperative computed tomography and (B) reconstruction images demonstrated thoracic endovascular aortic repair with occlusion of aneurysm and patency of arch vessels.
Discussion
Both American and European guidelines recommend aortic arch aneurysm intervention in nonsyndromic patients at a diameter of 5.5 cm, given the potential for rupture and other complications.2,3 For patients with low-risk aortic arch aneurysm, this involves arch replacement. However, endovascular repair has become an increasingly viable alternative to open surgery in high-risk patients.4
Traditionally, open surgical repair in patients with previous cardiac surgery is associated with high morbidity given the need for resternotomy, cardiopulmonary bypass, and hypothermic circulatory arrest.5 In contrast, endovascular approaches offer a minimally invasive solution that avoids many of these challenges, providing a reduction in morbidity, mortality, and hospital stay.6, 7, 8 There are several case reports that highlight the successful use of TEVAR after cardiac surgery.4, 5, 6, 7 Cases involving ductal occluder devices or branched endografts in the aortic arch have demonstrated effective exclusion of aneurysms, with stable imaging findings at follow-up intervals extending to 3 years.7 Furthermore, endovascular techniques lend themselves to reintervention. In cases where endoleaks or migration occur, additional endovascular procedures can often be performed without converting to open repair, which is especially valuable in patients with high operative risk.8 The rates of endoleak with a scalloped relay endograft have been reported to be approximately 4% to 5%. A multicenter study by Derycke and colleagues9 used the Relay endograft in 40 patients for a variety of indications, including thoracic aortic aneurysm and dissection. They reported a 5.4% rate of type 1a endoleak at 1 month, with no type 1B or 3 endoleaks.9 Similarly, a study by Sica and colleagues10 used fenestrated and scalloped endografts in the treatment of 49 patients with degenerative or postdissection aneurysmal disease, and penetrating aortic ulcer affecting the inner curve of the aorta. One patient had a type 1a endoleak requiring reintervention at 3 months. At the 36-month follow-up, 8.2% of patients had a type 2 endoleak and 2.1% had a type 3 endoleak.10 Hanna et al11 reported one of the longest follow-up periods of the Bolton Relay endograft. At a median follow up of 4.5 years, 5% developed type 1a endoleak related to device migration and disease progression, both of which required reintervention.11
Despite its advantages for high-risk patients, endovascular repair presents several short- and long-term challenges. The procedure's technical complexity, particularly in the aortic arch and ascending aorta, requires precise planning and deployment given the consequences of improper device positioning or inadvertent coverage of the supra-aortic vessels.12 This was even more important in the present case, where a LIMA-LAD graft was present. The risk of supra-aortic vessel occlusion therefore demands custom stent grafts to ensure branch patency, limiting the use of endovascular arch interventions in acute settings. Furthermore, the high-risk nature of the intervention requires careful preoperative planning. In this case, the clinical team considered several approaches and discussed the patient's case at multiple multidisciplinary team meetings. A carotid-subclavian bypass and endograft was considered but was felt to be too high risk given the LIMA-LAD graft. A branched device was not readily available to our center, with limited experience in its deployment. A scalloped design was chosen to reduce the risk of LSA coverage during deployment while providing a durable seal to avoid endoleak. This was an important consideration given the risk of a type 2 endoleak around the LSA leading to retrograde filling and aneurysm pressurization. In addition to detailed discussions, three-dimensional image segmentation software was used to plan deployment and print a silicone model, which provided a more tactile appreciation of the anatomical relationship of the aneurysm to the surrounding structures (Figure 6, Video 1).
Figure 6.
3-Dimensional Models Based on Preoperative Computed Tomography
(A to C) Silicone model demonstrating the relationship between the aneurysm and aortic arch branches as well as (D) the left internal mammary branch of the left subclavian artery.
Long-term disadvantages include the need for lifelong imaging surveillance to monitor for device-related complications such as endoleaks, migration, or aneurysm sac enlargement.7,8 This ongoing requirement can be burdensome for patients and resource-intensive for health care systems. Moreover, there remain limited long-term data on outcomes after endovascular repair in patients with aortic arch pathology. Some studies have noted that up to 42% of patients undergoing hybrid arch repairs experience late aortic complications, highlighting the importance of patient selection and long-term follow-up.1
To the best of our knowledge, this case is the first to outline the endovascular repair of an aortic arch aneurysm using a custom-made endograft in the context of a previous LIMA-LAD graft.
Conclusions
Endovascular repair of aortic arch aneurysms offers significant short-term advantages, particularly for patients deemed unfit for open surgery.4 When performed in experienced centers with careful planning, it can provide good outcomes.7 However, the potential for technical difficulties and late complications underscores the need for ongoing surveillance and continued research to establish robust long-term data. Future innovations in device design and procedural techniques may further enhance the safety and efficacy of this evolving therapeutic strategy.6
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Acknowledgments
The authors acknowledge Axial 3D for their support in generating the 3D models used in preoperative planning. Many thanks to Terumo for providing the stent schematics illustrated in Figure 3.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
Visual Summary.
| Time | Events |
|---|---|
| Presentation | A 75-year-old man presented to the emergency department with syncope. He was found to have a 5.9 × 5.7 × 5.2 saccular distal aortic arch aneurysm on CT. Medical history included prior CABG (LIMA-LAD and SVG-RCA), NSTEMI, atrial fibrillation, diabetes, and hypertension. |
| MDT | Case discussed at multidisciplinary complex aortic meeting. Patient was deemed at high risk for open surgery or carotid-subclavian bypass given LIMA-LAD graft. A plan was made for endovascular repair with custom Bolton Relay stent graft. |
| Operation | Patient underwent successful TEVAR via bilateral femoral access. A Bolton Relay custom scalloped thoracic stent graft was deployed to preserve LIMA-LAD flow and exclude aneurysm. There were no intraoperative complications or hemodynamic instability. |
| Discharge | Patient developed a single episode of fast atrial fibrillation; the rate was controlled with bisoprolol. Discharged home on postoperative day 9. |
| 30-d follow-up | Admitted and discharged in the interim for permanent pacemaker insertion after conversion pauses leading to syncope. CT scan demonstrated stable stent graft position, patent aortic arch branches, and no endoleak. |
| 6-mo follow-up | In-clinic review indicated good recovery, with no further complications. |
Appendix
Three-Dimensional Illustration of the Aorta Demonstrating the Relationship of the Arch Aneurysm to the Arch Vessels and the Left Internal Mammary Artery
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Associated Data
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Supplementary Materials
Three-Dimensional Illustration of the Aorta Demonstrating the Relationship of the Arch Aneurysm to the Arch Vessels and the Left Internal Mammary Artery