Endovascular treatment of abdominal aorta aneurysm rupture previously treated with endoprothesis
(Portuguese
PDF version)
Pierre
Galvagni Silveira1, Gilberto do Nascimento Galego1,
Cristiano Torres Bortoluzzi1, Ricardo Perez2,
Humberto Jorge da Silva1, Luiz André Simon1
1.
SOS Cardio, Department of Clinical Surgery, Universidade Federal de
Santa Catarina.
2. Eng. MsC, Department of Mechanical Engineering,
Universidade Federal de Santa Catarina.
Correspondence:
Pierre Galvagni Silveira
Rua Irmão Joaquim, 122
CEP 88020-620 - Florianópolis - SC
E-mail: pierre@matrix.com.br
ABSTRACT
The
purpose of this study is to demonstrate the possibility of providing
endovascular treatment to patients with abdominal aortic aneurysm
(AAA) rupture, even when they had previously received such a treatment.
We describe a case of a 74-year-old patient who presented an AAA.
This patient was subjected to the implantation of an endoprosthesis
and 20 months later there was a rupture of the aneurysm due to a
Type III endoleak. The patient was successfully treated with the
implantation of a new endoprosthesis. The patient presented a satisfactory
postoperative outcome and was discharged eight days after the surgery.
Even though further technological development of the currently available
devices is necessary, we believe that in critical situations, as
in the case described here, the use of this technique is appropriately
valid.
Key
words: abdominal aortic aneurysm, rupture, blood vessel prosthesis
implantation.
Palavras-chave: aneurisma da aorta abdominal, ruptura,
implante de prótese vascular.
J
Vasc Br 2002;1(2):129-32.
INTRODUCTION
Since the
first report made by Parodi et al. in 1991, the endoluminal treatment
of abdominal aortic aneurysms has been gaining momentum.1 Several studies
report aneurysm rupture after endovascular repair, which has an incidence
of between 0.5% to 1%.2 The treatment recommended for these cases consists
in removing the endoprosthesis and treating the ruptured AAA by conventional
surgery. This procedure is associated with high mortality rates. At
present, we know the available devices have had structural limitations
that have been corrected with technological improvement, especially
in the fields of biomaterials and metal alloys. The problems related
to material fatigue, either of metal alloys or of the fabric that cover
them, are the major cause of failures in the endoprosthetic structure.
In this
case report, we describe the rupture of an AAA in a patient previously
treated with a first-generation device. The aneurysm was successfully
corrected by the implantation of a new endoprosthesis.
CASE REPORT
Male, 74-year-old patient with history of brain surgery for the correction of hemorrhagic stroke due to the rupture of a cerebral aneurysm and implantation of a ventriculo-peritoneal shunt, severe coronary failure (acute myocardial infarction four years ago), dilated myocardiopathy and chronic obstructive pulmonary disease. The diagnosis of AAA with a 65mm diameter was made 20 months ago. Given the contraindication of conventional surgery, the patient immediately received the implantation of an aortobiiliac endoprosthesis (Apolo®) measuring 28x12 mm and 167 mm in length. The immediate postoperative control and at 90 days showed total exclusion of the AAA (Figure 1). After the last visit, the patient did not return for follow-up as recommended. Seventeen months after the last visit, the patient was attended to at an ER due to abdominal pain and a syncopal episode followed by low blood pressure. On physical examination, abdominal pain was present at palpation and a pulsatile tumor was observed in the epigastric region. The abdominal ecography showed free fluid in the abdominal cavity with a bulky retroperitoneal hematoma. The hemoglobin level was 7.2 g/dl and the creatinine level was 2.33 mg/dl. After the diagnosis of a ruptured AAA, an emergency treatment was indicated and, given the multiple comorbidities of the patient and the high risk of a conventional intervention, we recommended endoluminal treatment, which was carried out after the family signed an informed consent. Under general anesthesia, both femoral bifurcations were dissected. The common femoral artery was catheterized and an aortography was performed with a pigtail catheter. The aortography revealed a remarkable contrast leak at the level of the endoprosthetic body (Figure 2). At lateral fluoroscopy, it was possible to identify a fracture in the endoprosthetic structure (Figure 3). After that, a conical endoprosthesis (Apolo®) of 28x18 mm with 120 mm in length was implanted. The arteriography showed a persistent endoleak close to the proximal anastomosis, which required the implantation of another two straight endoprostheses of 28x28 and 31x31, both 85 mm in length. The embolization of the contralateral iliac branch was carried out with the implantation of Gianturco coils. Control aortography revealed that the endoleak was corrected and that the AAA was totally removed. Afterwards, a femoral-femoral crossover bypass graft was carried out with an 8-mm polytetrafluoroethylene (PTFE) prosthesis.
 Figure
1 - Control by helical computed tomography,
March 2001.
Figure
2 - Aortography with remarkable contrast
leak at the endoprosthetic body.
Figure
3 - Failure on the endoprosthetic structure.
At the
hemodynamic level, the patient's outcome was satisfactory despite a
slight respiratory insufficiency that resulted from the underlying disease.
The patient showed airway noises on the second day after surgery, when
an oral diet was initiated. On physical examination, he had an important
hematoma on the left flank and his abdomen was depressible and painless.
Renal dysfunction was corrected without hemodialysis or improved spontaneously.
On the eighth day after surgery, the patient was submitted to a new
helical computed tomography, which showed that the rupture was repaired
(Figures 4, 5). The patient was discharged from hospital on the same
day.
Figure
4 - Axial section in postoperative
control showing exclusion of ruptured AAA with remarkable residual retroperitoneal
hematoma.
Figure
5 - Three-dimensional reconstruction
showing exclusion of ruptured AAA and presence of femoral-femoral crossover
bypass graft.
DISCUSSION
The aim
of treating AAA is to prevent aneurysm rupture and subsequent death.
The short and medium term effectiveness of endovascular treatment is
99.2%, against a rupture rate of 11% in untreated patients. The successful
implantation of an endoprosthesis considerably reduces the risk of aneurysm
rupture.3-4 After endovascular treatment, the size of an AAA decreases
on average 4 mm/year. If any kind of endoleak is present, the aneurysm
diameter can stabilize or increase. For this reason, it is very important
to have an appropriate radiological follow-up of patients who have undergone
an endovascular surgery.5
Zarins
et al., in a series of 1,067 patients assessed after the implantation
of endoprostheses, have reported nine ruptures (0.9%), two during the
implantation of the endoprosthesis and seven during the follow-up period
(between three weeks and 24 months). Of these seven patients, only two
presented endoleak (types I and II) during the follow-up period.3 Bernhard
et al. have reported seven ruptures in a study conducted with 852 patients
with AAA treated with a Guidant/EVT device.6 Conversion in conventional
surgery for the removal of the endoprosthesis is a procedure with high
morbidity and mortality, despite the fact that the endoprosthesis is
a mechanical barrier to hemorrhage, and therefore offers the possibility
of postponing the treatment for some time. This type of surgery presents
an increased level of difficulty, especially at the moment of aortic
cross-clamping and removal of the endoprosthesis; in this case, mortality
can exceed 43%.5-8 Few studies report on the experience with the endovascular
repair of ruptured aneurysms; among these few studies we have the one
carried out by Ohki et al.9 Likewise, reports on the endovascular treatment
of patients with AAA rupture previously treated with this method are
quite rare. Ramaiah et al. have reported a case in which the patient
died four weeks after hospital discharge.2 In our case and in the case
described by the Phoenix group, some technical aspects should be analyzed.
The selection of the device did not previously require any imaging method
for determining the size of the device since, as the patients had already
been treated with this technique, all the information on the characteristics
of the AAA was already known. This allowed treating the patient more
quickly. On the other hand, several endovascular devices were available,
thus allowing for undelayed implantation. In both cases, the patients
also presented comorbidities that were contraindicative to conventional
treatment.
In the
case described here, we had all the information necessary for the new
implantation from the moment the patient was admitted to the emergency
room, regardless of the necessity for any type of additonal imaging
exam. In the subsequent hemodynamic analysis, we can confirm the failure
in the structure of the endoprosthetic body by using fluoroscopy only.
The leaks secondary to structural fatigue (type III), or secondary to
migration, are easily identified through plain abdominal two-dimensional
x-ray. Thus, when AAA rupture is suspected in a patient previously treated
with endovascular surgery, the diagnosis can be established by anamnesis
and by radiography. This occurred in the case described herein. On the
other hand, this could have been avoided if the patient had done the
follow-up exams as recommended. Nowadays, we recommend that all patients
have a clinical follow-up every six months, which includes plain x-ray.
Helical computed tomography is requested every 12 months. Type I leaks
are usually treated during the same hospital stay; however, leaks secondary
to malfunction of the device are normally related to material fatigue
and, consequently, to the timing of implantation. This shows the importance
of follow-ups in the medium and long term. Special attention should
be given to patients with "hostile" anatomical features, mainly
characterized by a highly angulated proximal neck, since this characteristic
makes the device more vulnerable to repeated movements. These patients
should be closely cared for. The endovascular repair of AAA has been
progressively used despite frequent reports of failure, which usually
involve leaks. Even so, endovascular treatment has similar results in
terms of prevention of ruptures and reinterventions in the short term
when compared to conventional surgery.10-11
We believe
endovascular repair of aortic ruptures is considered efficient and less
risky for the patient in centers that offer specialized endovascular
services and sophisticated imaging equipment. This is especially true
for patients previously treated with endoprostheses. However, long-term
clinical studies are still necessary.
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