Asian Cardiovasc Thorac Ann 2007;15:e25-e27
© 2007 Asia Publishing EXchange Ltd
Emergency Stent-Grafting for Patients Over 85 Years of Age with Thoracic Aortic Rupture
Kiyofumi Morishita, MD,
Yoshihiko Kurimoto, MD,
Nobuyoshi Kawaharada, MD,
Hisayoshi Osawa, MD,
Toshiyuki Maeda, MD,
Tomio Abe, MD
Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
For reprint information contact: Kiyofumi Morishita, MD Tel: 81 11 611 2111 Fax: 81 11 613 7318 Email: kmori{at}sapmed.ac.jp, Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, South 1 West 16, Central Ward, Sapporo 060-8543, Japan.
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ABSTRACT
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Conventional open repairs of thoracic aortic ruptures carry a high mortality and morbidity in patients over 85 years of age. Less invasive procedures may therefore be required to treat such elderly patients. An 87-year-old woman and 92-year-old man who had undergone emergency endovascular stent-grafting for thoracic aortic ruptures survived to discharge, despite critical conditions on admission.
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INTRODUCTION
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Traditional open repair of thoracic aortic rupture still remains a great challenge. The mortality rate in elderly patients is high.1 Less invasive procedures may therefore be required to treat elderly patients. In our institution, octogenarian or nonagenarian patients with thoracic aortic rupture are primarily considered as potential candidates for less invasive endovascular stent-grafting. We report two cases of thoracic aortic rupture in an 87-year-old woman and a 92-year-old man successfully treated by emergency endovascular stent-grafting.
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CASE REPORTS
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PATIENT 1
An 87-year-old woman with a history of hypertension presented with acute back pain and shock. On admission, her blood pressure was 70/40 mm Hg. An emergency computed tomography (CT) scan showed a thoracic aortic aneurysm from the mid-descending aorta to above the celiac artery with a maximum diameter of 7 cm, and massive right pleural and retroperitoneal effusion. The patient was diagnosed as having a ruptured thoracoabdominal aneurysm and was immediately taken to an operating room to undergo endoluminal stent-grafting, selected due to advanced age and renal dysfunction (creatinine: 2.6 mg·dL–1). A delivery system was inserted into the left common iliac artery because of extensive atherosclerotic femoral arteries. A hand-made stent-graft2 was deployed 5 mm above the celiac artery. As digital subtraction angiography revealed distal endoleak, balloon dilatation was performed to seal it (Figure 1
). As injury to the common iliac artery occurred at the time of removal of the delivery device, the artery was reconstructed with a 6 mm gelatin-sealed knitted Dacron graft (Gelsoft, Vascutek, Scotland, UK). The operative time was 180 minutes.
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Figure 1. A hand-made stent graft was deployed from the mid-thoracic aorta to 5 mm above the celiac artery.
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The patient was extubated on the second post-procedural day and transferred to a rehabilitation facility 6 days later without any spinal cord ischemia. The patient was discharged after two months of rehabilitation and was doing well at 2 year follow-up.
PATIENT 2
A 92-year-old man was transferred to our hospital with a diagnosis of ruptured aneurysm. Computed tomography scan showed a distal arch aneurysm with a maximum diameter of 5 cm and massive left pleural effusion. The extent of the aneurysm involved the proximal one third of the descending thoracic aorta. The referring physician requested stent-grafting as the patient had advanced prostate carcinoma. A delivery system was advanced into the distal arch aneurysm through the right femoral artery. A brachial-femoral guidewire was used because of a tortuous aorta.3 Cardiac arrest was pharmacologically induced to precisely deploy the stent graft. Temporary pacing was started immediately after deployment. Asystole lasted for 30 seconds, and pacing alone was used for resuscitation. The left subclavian artery was intentionally covered by the stent graft for the purpose of complete exclusion of the aneurysm (Figure 2). The procedural time was 70 minutes.
The patient underwent tracheostomy on the fourth day due to respiratory insufficiency and was transferred to a rehabilitation facility 7 days after the stent-grafting. Two weeks later, he was weaned from mechanical ventilation. He had recovered to the point of being able to walk with a walker 3 months after stent-grafting.
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DISCUSSION
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Whether octogenarians or nonagenarians with acute thoracic aortic disease should be operated upon remains controversial due to poor outcomes.4 Even if patients survive open repairs, life expectancy and functional independence are limited. In addition, interventions in elderly patients are associated with higher morbidity and mortality rates, which result in high hospital costs. Considering the recent trend of reduced reimbursement, open repair may not be appropriate in such elderly patients.
The in-hospital mortality rate in patients over 77 years of age with ruptured thoracoabdominal aneurysms in the United States was about 65% from 1988 to 1998; a figure that does not seem to justify operating on elderly patients.1 Surprisingly, Girardi and Coselli5 reported no mortality in octogenarian patients with ruptured thoracoabdominal aneurysms, while another expert team6 reported 50% mortality in patients over 79 years of age who had undergone emergency descending and thoracoabdominal aortic aneurysm repair. In our institution, over the last 3 years, all 4 patients above 80 years of age who underwent emergency graft replacement for ruptured thoracic aortic aneurysms died within 30 days of the operation, while the 2 patients reported here survived to discharge. Despite limited experience, the results in these 2 patients encourage us to continue to apply endoluminal stent-grafting in this population.
Doss and associates reported the superiority of stent-grafting over conventional operations in patients with acute thoracic aortic ruptures.7 Recently, they reported that stent-graft-related mortality and morbidity increased at midterm follow-up.8 This paper inevitably raises the question of whether re-intervention should be performed in elderly patients with late complications. Its indication depends on the invasiveness of the procedure and "biological age": Success of re-intervention is not always guaranteed in elderly patients who survive the first procedure. Such patients may need a longer time and higher costs to recover because they are older than they were at the time of the first procedure. We have to take these aspects into consideration. Re-intervention may need to be reserved for very carefully selected patients.
There are some technical issues specific to elderly patients regarding endoluminal stent-grafting. A brachial-femoral guidewire is useful as elderly patients often have a tortuous or angled aorta. The stiff delivery system can be navigated safely to the target lesion by applying tension on both ends of the brachial-femoral guidewire.2 Insertion through the common iliac artery is the preferred method in the presence of extensive atherosclerotic disease often seen in the femoral artery of aged patients. As the iliac artery, a common site of injury, is exposed, diagnosis and treatment of arterial injury can be easily performed. Pharmacologically induced cardiac arrest is frequently used to achieve precise deployment, especially when the aneurysm is in close proximity to the branch vessels. In elderly patients, a ventricular pacing lead should be positioned at the right ventricle in case of an emergency. As emergency conditions require expeditious procedures, these techniques may appear to be time-consuming. However, survival of elderly patients decreases dramatically with even an isolated complication. We believe that these adjunctive techniques are of paramount value to prevent any complications.
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REFERENCES
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- Cowan JA Jr, Dimick JB, Wainess RM, Henke PK, Stanley JC, Upchurch GR Jr. Ruptured thoracoabdominal aortic aneurysm treatment in the United States: 1988 to 1998. J Vasc Surg 2003;38:319–22.[Medline]
- Morishita K, Kurimoto Y, Kawaharada N, Fukada J, Hachiro Y, Fujisawa Y, et al. Descending thoracic aortic rupture: role of endovascular stent-grafting. Ann Thorac Surg 2004;78:1630–4.[Abstract/Free Full Text]
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- Girardi LN, Coselli JS. Repair of thoracoabdominal aortic aneurysms in octogenarians. Ann Thorac Surg 1998;65:491–5.[Abstract/Free Full Text]
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- Doss M, Balzer J, Martens S, Wood JP, Wimmer-Greinecker G, Fieguth HG, et al. Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience. Ann Thorac Surg 2003;76:1465–70.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
