LATE RUPTURE OF AN ABDOMINAL AORTIC ANEURYSM AFTER PARODI S ENDOPROSTHESIS REPLACEMENT

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1 Dipartimento di Medicina Chirurgia e Odontoiatria Università degli Studi di Milano OSPEDALE SAN PAOLO POLO UNIVERSITARIO Divisione di Chirurgia III Clinica Chirurgica Generale Direttore: Prof. Roberto Scorza LATE RUPTURE OF AN ABDOMINAL AORTIC ANEURYSM AFTER PARODI S ENDOPROSTHESIS REPLACEMENT Marco De Monti Giorgio Ghilardi Andrea Odero Giuseppina Labagnara Roberto Scorza Università degli Studi di Milano Dipartimento di Medicina Chirurgia e Odontoiatria Cattedra di Clinica Chirurgica Generale (Direttore: Prof. R. Scorza) Case report Authors address: Dott. Giorgio Ghilardi Università degli Studi di Milano Dipartimento di Medicina Chirurgia e Odontoiatria Cattedra di Clinica Chirurgica Generale Via A. Di Rudinì, Milano giorgio.ghilardi@unimi.it 1

2 Introduction LATE RUPTURE OF AN ABDOMINAL AORTIC ANEURYSM AFTER PARODI S ENDOPROSTHESIS IMPLANTATION The first successful aortic endoprosthesis placement in man was performed trough a femoral approach by Juan Parodi, an Argentinean surgeon of Italian origin, in November This was the result of a genial insight, which was in agreement with the general trend in the 90 s to achieve surgical efficacy while minimizing invasiveness, pain, and complications. This trend found its highlight in the development of videolaparoscopic surgery while in the field of vascular surgery invasive radiology begun to offer promising prospects in the management of obstructive and thrombotic pathology as well as in the embolization of small aneurysmatic and angiomatous lesions.. In 1993 Parodi reported his experience on a few dozen patients in whom the so called stent-grafts were placed, i.e. vascular prostheses identical to those employed during traditional surgery modified by suturing anchoring metallic stents to the extremities. These stents, once expanded, allowed the prosthesis to remain anchored to the aortic wall (1,2,3). Since then, there has been a rapid progress in technologies, materials, and implant procedures resulting in the development of very effective devices. Covered-stents are easier to implant and, being modular and bifurcated, they may also be applied to aorto-iliac aneurysms. However, the true efficacy of the different types of prostheses used in vascular surgery may be fully evaluated only in a couple of years, when reliable five-year follow up data will be available for analysis. This report describes a case of aortic aneurysm rupture who had undergone stent-graft endoprosthesis placement two years before. Case report Z.G. is an eighty-year-old white Caucasian male. His past medical history is relevant for an acute myocardial infarction at age 62, atrial fibrillation, and pancytopenia associated with hypoplastic marrow diagnosed one year ago and treated with chemotherapy, hypertension requiring medications, and Parodi s prosthesis implantation two years ago. The patient was referred to our service for persistent lumbar pain not responding to commonly employed analgesics, which had been present for over 30 days. A lateral abdominal film showed the two stents, which were evidently misaligned (fig.1). An abdominal sonogram showed an aneurysmatic dilatation with a diameter of 55 mm (fig. 2). A CT scan confirmed endoprosthesis dislodging with a wide leakage (fig. 3) and a double lumen aorta (fig.4) as well as a periaortic collection of contrast media pointing out the presence of aneurysmal wall rupture. The patient underwent traditional surgery through a laparotomic approach. Intraoperatively, complete detachment of the distal stent and curling of the prosthesis was confirmed, together with an evident rupture of the distal posterior wall and retroperitoneal haematoma. A traditional straight prosthesis was placed. No bacterial contamination was detected by culture of both a fragment of the aneurysmatic thrombus and of a preaortic lymph node. The post-operative course was uneventful except for a substantial transfusion requirement (9 units of packed red cells, 4 units of fresh frozen plasma, and 4 units of platelets), which was related to the known haematological condition of the patient. He was discharged, surgically cured, on post-operative day 10. 2

3 Discussion One of the biggest problems of first generation stent-graft endoprostheses was caudal migration and dislocation, which occurred as a consequence of inadequate distal and proximal anchoring. In fact, these non-autoexpandable devices needed to be expanded and fixed to the aortic wall by means of the sole radial force of the balloon during the placement procedure. According to the Italian Trial of endovascular AAA exclusion using the Parodi endograft, 31% of these patients required traditional surgery within 18 months of endograft placement (4). Currently, many prostheses are autoexpandable and the dilation performed during placement by means of the balloon may allow a more secure anchoring but does not affect the actual expansion of the stent. In addition, as opposed to presently available covered-stents, stent-grafts had no complete frame and relied on proximal stent holding capacity against systolic flow and sphygmic wave; moreover, the distal part of the stent had to anchor at the bifurcation which was frequently not disease-free and extensively calcified (4). Endoleak formation (5,6,7) which occurs in most severe cases of prosthesis dislocation, might currently be reduced thanks to the use of completely framed prostheses with thermal memory which are autexpandable and, most importantly, bifurcated; in fact, the bifurcation of a well-positioned stent, together with iliac anchoring, provide further endoprosthesis stability (8).. Endoprosthesis development has proceeded in parallel with imaging advances allowing spiral CT evaluations to non-invasively provide accurate measurements of aortic and iliac diameters. This imaging modality also allows monitoring of the status of the thrombus especially at the level of the aortic neck, and to estimate the degree of calcification of the aortic wall to which anchoring occurs. This information is of critical importance to choose the type of procedure to be recommended to the patient, i.e. traditional versus endovascular surgery, and, in case the latter is planned, to select the most appropriate endoprosthesis to be implanted (9,10). Conclusions Endovascular surgery has a growing role in the management of aortic aneurysms, in fact is presently the first choice approach to a substantial proportion of aneurysms and is bound to have a growing spectrum of indications. Specifically, thoracic aneurysms (11), for which traditional surgery carries significant morbidity and mortality, are lesions for which an endovascular approach may offer great advantages. Accurate spiral CT angiography of the aorta and iliac bifurcation is of paramount importance both for establishing the indication for endoprosthesis placement and to guide the selection of the most appropriate endoprosthesis type and size. Endoprosthesis insertion should be performed in the operating room in order to provide maximal sterility and to rapidly convert to traditional surgery if necessary (12). Team members should ideally include both a surgeon and an invasive radiologist. Close follow up by ecodoppler and CT angiography (performed with biphasic technique, i.e. arterious and venous) (13) is critical both for monitoring patients carrying old endoprostheses which are more prone to endoleakage, migrations and late aortic ruptures (14), and for the validation of new techniques (15). 3

4 REFERENCES 1) Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysm. Ann Vasc Surg 1991; 5: ) Parodi JC, Barone HD, Schonholz C. Transfemoral endovascular treatment of aortoiliac aneurysms and arteriovenous fistulas with stended Dacron grafts. In Veith F, Current problems in Vascular Surgery, vol 5. St Louis, Quality medical Publishing 1993: 264 3) Parodi JC. Endovascular repair of abdominal aortic aneurysm and other arterial lesions. J Vasc Surg 1995; 21: ) Coppi G, Moratto R, Silingardi R, Tusini N, Vecchioni R, Scuro A, Stiramiglio P, Adami CA. The Italian Trial of endovascular AAA exclusion using the Parodi endograft. J Endovasc Surg 1997; 4: ) Wain RA, Marin ML, Ohki T, Sanchez LA, Lyon RT, Rozenblit A, Suggs WD et al. Endoleaks after endovascular graft treatment of aortic aneurysm: classification. Risk factors and outcome. Vasc Surg 1998; 27: ) Matsumura MJ, Moore WS. Clinical consequences of periprosthetic leak after endovascular repair of abdominal aortic aneurysm. J Vasc Surg 1998; 27: ) White GH, May J, Yu W. Endoleak - a proposed new terminology to describe incomplete aneurysm exclusion by an endoluminal graft. J Endovasc Surg 1996; 3: ) Chute TAM, Wendt G, Hopkinson BR, Scott RAP, Risberg B, Kieffer E et al.bifurcated stent-graft for abdominal aortic aneurysm. Cardiovasc Surg 1997; 5: ) Bayle O, Branchereau A, Rosset E, Guillemot E, Beaurain P, Ferdani M and Jausserau JM. Morphologic assesment of abdominal aortic aneurysms by spiral computed tomographic scanning. J Vasc Surg 1997, 26: ) Rubin JD, Paik DS, Johnston PC, Napel S. Measurement of the aorta and its branches with helical CT.Radiology 1998; 206: ) Dake MD, Miller DC, Mitchell RS, Semba CP, Moore KA, Sakai T. The "first generation" of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta. J Thorac Cardiovasc Surg 1998; 116(5): ) Gross GM, Johnson RC, Roberts RM. Results of peripheral endovascular procedures in the operating room. J Vasc Surg 1996; 24: ) Golzarian J, Dassaussois L, Abada HT, Gevenois PA, Van Gansbeke D, Ferreira J et al. Helical CT of aorta after endoluminal stent-graft therapy: value of bifasic acquisition. AJR 1998; 171: ) Lumsden A, Allen RC, Chaikof EL, Resnikoff M, Moritz MW, Gerhard H et al. Delayed ruptured of aortic aneurysms following endovascular stent grafting. Am J Surg 1995; 170: ) Fillinger MF. Postoperative imaging after endovascular AAA repair. Seminars Vasc Surg 1999; 12(4):

5 Summary Endovascular surgery as a whole, and specifically in the context of aortic aneurysms, is a very interesting methodology the potential of which is increasingly being recognized. Follow up information on patients who underwent these procedures will be critical to validate the different techniques which have been developed and to identify the most appropriate situations for this type of surgical procedures. The authors present a case of aortic aneurysm rupture who had undergone Parodi s endoprosthesis placement two years before. CT angiographic evaluation showed a wide endoleak due to distal stent detachment, a complete dislodging of the endoprosthesis itself and retroperitoneal haematoma. Prosthesis replacement through a laparotomic approach was carried out and the patient was discharged 10 days postoperatively, surgically cured. KEY WORDS: Endovascular surgery, intraluminal graft, endovascular graft, aortic aneurysm, stentgraft. 5

6 LEGENDS FIG 1 Lateral abdominal X-ray: the two misaligned endoaortic stents can be seen. FIG.2 Abdominal sonogram: The metallic stents can be identified within an aneurysmatic dilatation of 55 mm in diameter. FIG.3 Contrast-enhanced abdominal CT: endoprosthesis dislodging with wide leakage. FIG.4 Contrast-enhanced abdominal CT: double-lumen aorta with periaortic contrast medium leakage. 6