Free Esophageal Perforation Following Hybrid Visceral Debranching and Distal Endograft Extension to Repair a Ruptured Thoracoabdominal Aortic

Transcription

1 Free Esophageal Perforation Following Hybrid Visceral Debranching and Distal Endograft Extension to Repair a Ruptured Thoracoabdominal Aortic Aneurysm

2 History A 56-year-old gentleman, who had been referred to us more than 5 years ago with Large Descending Thoracic aortic aneurysm. C/o back pain, abdominal angina, LT leg claudication Heavy smoker, HTN, severe COPD

3 CTA of Aorta 2007 Descending Thoracic aortic aneurysm (7.3 cm) Infra renal AAA : 3.1cm Occluded celiac artery, SMA stenosis. Right renal artery stenosis with atrophic RT kidney Occluded LT CIA & EIA.

4 CTA: DTAA

5 CTA DTAA: 7.3cm IR AAA: 3.1cm

6 Repair March 2007 :Endovascular repair of the thoracic aneurysm was done using three Medtronic excluder stent graft. August 2007, CTA : significant type III endoleak secondary to separation at the junction of the lower two stents. No change in the size of the aneurysm. No migration of the stent.

7 August 2007

8 Endovascular Repair Medtronic stent graft was deployed overlapping the previous stents down to the celiac artery. F/U CTA: complete sealing of the aneurysm without evidence of leak. The maximum diameter of the thrombosed aneurysm decreased to 7.0 cm.

9 CTA 2008

10 CTA 2008

11 2011 Left leg claudication and abdominal angina got worse and he became cachectic. CTA: Increase size of supra celiac aorta (8.6cm) and IRAAA(6.6cm). Occlusion of celiac artery. Severe stenosis of SMA and both renal artery with atrophic RT kidney. Occlusion of the left CIA & EIA.

12 CTA 2011 Supraceliac Aorta 8.6cm SMA stenosis

13 CTA 2011 Bilateral renal artery stenosis IRAAA 6.6cm

14 CTA 2011

15 CTA 2011 Type V TAAA LT CIA & EIA occlusion

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17 Renal Scan Nephropathic, non-functioning small right kidney.

18 What To Do Next? Branched stent graft. Fenestrated stent graft. Hybrid procedure. Open surgical repair.

19 Rupture TAAA He presented to ER with severe back pain and hypotension. Stat C-X Ray: contained ruptured thoracic aneurysm.

20 Surgery He was rushed to OR. At exploration: He had large supra renal hematoma extending to the chest and posterior mediastinum. The infrarenal portion of his TAAA was not ruptured

21 Surgical Repair of Infrarenal portion of TAAA Left kidney was harvested first for auto transplant. Infrarenal aortic clump was applied and Aorto Bifemoral Bypass was created. Aorto-SMA bypass was done from the distal portion of the ABFB graft.

22 Endovascular Repair of Thoracic portion of TAAA Two Medtronic Endurant graft were deployed from the previous thoracic stent graft to inside the aortobifemoral bypass graft via the left limb of the ABFB graft. Auto transplant of the previously harvested LT Kidney to the right limb of our aortobifemoral bypass graft.

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24 postoperatively No paraplegia. Renal profile : Normal. Abdominal angina resolved. Tolerated oral diet well.

25 Postoperative CTA No endoleak. Large old retroperitoneal and posterior mediastinal hematoma. patent aorto-sma bypass graft. good flow to the kidney.

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27 Postoperative Discharged : 2 week after his surgery 3 days later, he presented To ER with severe back and chest pain and sepsis. CTA: No endoleak. Bilateral pleural effusion. air-fluid level and multiple foci of air within the hematoma suggestive of infection.

28 CTA Infected posterior mediastinum Hematoma. Bilateral pleural effusion.

29 Surgery Bilateral chest tube were placed. Bilateral thoracotomies and decortications. 4 days: Developed chest pain, abdominal pain and hematemesis.feeding tube solution start c/o from LT chest tube. barium swallow: Lower esophageal perforation EGD: long tear at the posterior wall of lower esophagus secondary to ischemia.

30 Barium swallow

31 Management esophageal stent was placed. Repeated BS revealed persistent esophageal leak. Old stent removed and new one placed by thoracic surgeon. Repeated BS: Persistent leak. Old stent removed and largest stent was placed by IR Repeated BS revealed persistent leak.

32 Surgery Esophageal exclusion by cervical esophagostomy, stapling GE junction, and feeding jejunostomy. Did well after that and discharged home on tube feeding.

33 3 Months Later He gain some weight TPN: 2 weeks. Retrosternal Gastric pull-up reconstruction (anterior medistinum). Tolerated oral feeding well Discharged home on life long antibiotics.

34 Lessons Learned Ruptured TAAA can be treated with hybrid technique without thoracotomy. Renal auto transplant is an alternative way to preserve the kidney with excellent outcome. Esophageal rupture after RTAAA is a rare complication, very difficult to manage, and associated with high morbidity and mortality.

35 Lessons Learned The cause of esophageal rupture can be multi factorial: Ischemia, Pressure necrosis, infection. Esophageal Stent placement is ineffective way to treat esophageal rupture especially in distal perforation. Early aggressive surgical exclusion of the perforated esophagus is crucial for survival.

36 Thank You Questions?

37 Free Esophageal Perforation Following Hybrid Visceral Debranching and Distal Endograft Extension to Repair a Ruptured Thoracoabdominal Aortic Aneurysm