Elective visceral hybrid repair of type III thoracoabdominal aortic aneurysm

Abstract

Introduction. According to the classification given by Crawford et al. type III thoracoabdominal aortic aneurysm (TAAA) is dilatation of the aorta from the level of the rib 6 to the separation of the aorta below the renal arteries, capturing all the visceral branch of aorta. Visceral hybrid reconstruction of TAAA is a procedure developed in recent years in the world, which involves a combination of conventional, open and endovascular aortic reconstruction surgery at the level of separation of the left subclavian artery to the level of visceral branches of aorta. Case report. We presented a 75-years-old man, with elective visceral hybrid reconstruction of type III TAAA. Computerized scanning (CT) angiography of the patient showed type III TAAA with the maximum transverse diameter of aneurysm of 92 mm. Aneurysm started at the level of the sixth rib, and the end of the aneurysm was 1 cm distal to the level of renal arteries. Aneurysm compressed the esophagus, causing the patient difficulty in swallowing act, especially solid food, and frequent back pain. From the other comorbidity, the patient had been treated for a long time, due to chronic obstructive pulmonary disease and hypertension. In general endotracheal anesthesia with epidural analgesia, the patient underwent visceral hybrid reconstruction of TAAA, which combines classic, open vascular surgery and endovascular procedures. Classic vascular surgery is visceral reconstruction using by-pass procedure from the distal, normal aorta to all visceral branches: celiac trunk, superior mesenteric artery and both renal arteries, with ligature of all arteries very close to the aorta. After that, by synchronous endovascular technique a complete aneurysmal exclusion of thoracoabdominal aneurysm with thoracic stent-graft was performed. The postoperative course was conducted properly and the patient left the Clinic for Vascular Surgery on postoperative day 21. Control CT, performed 3 months after the surgery showed that the patient's vascular status was uneventful with functional visceral by-pass and with good position of a stent-graft without a significant endoleak. Conclusion. Visceral hybrid reconstruction represents a complementary surgical technique to that with open reconstruction of TAAA. This approach is far less traumatic to a patient, and is especially important in patients with lot of comorbidities, because there is no need for thoracotomy, and ischemicreperfusion injury of the body is reduced to a minimum.Uvod/Cilj. Aneurizme torakoabdominalne aorte (TAAA) tipa III predstavlja prosirenje aorte od nivoa 6. rebra, pa sve do dela aorte ispod odvajanja renalnih arterija, zahvatajuci sve visceralne grane aorte.Visceralna hibridna rekonstrukcija TAAA tipa III predstavlja proceduru razvijenu u svetu zadnjih godina, a koja podrazumeva kombinaciju klasicne i endovaskularne hirurgije u rekonstrukciji aorte, od nivoa odvajanja leve podkljucne arterije, pa sve do racve bedrenih arterija. Prikaz bolesnika. U radu je prikazan bolesnik muskog pola, star 75 godina, kod koga je ucinjena elektivna visceralna hibridna rekonstrukcija TAAA tipa III. Bolesniku je kompijuterizovanom skenerskom aortografijom pocetkom 2010. godine dijagnostikovana TAAA tipa III sa najvecim poprecnim precnikom od 92 mm. Pocetak aneurizme bio je u nivou sestog rebra, a kraj na 1 cm distalno od odvajanja renalnih arterija. Aneurizma je vrsila kompresiju na jednjak, zbog cega je bolesnik imao otezan akt gutanja narocito cvrste hrane, ceste bolove u ledjima i lumbalnom delu kicme. Od drugih komorbidnih stanja, bolesnik se duze vreme lecio od hronicne opstruktivne bolesti pluca i hipertenzije. U opstoj endotrahealnoj anesteziji, uz epiduralnu analgeziju, kod bolesnika je ucinjena visceralna hibridna rekonstrukcija TAAA koja predstavlja kombinaciju klasicne, otvorene vaskularne hirurgije i endovaskularne procedure. Klasicna vaskularna hirurgija podrazumevala je visceralnu rekonstrukciju by pass procedurom sa distalne, normalne aorte, svih visceralnih grana: celijacnog trunkusa, gornje mezentericne arterije i obe renalne arterije, uz ligiranje istih na samom odstupu od aorte. U sledecem aktu, sinhrono endovaskularnom tehnikom izvrsena je ekskluzija kompletne aneurizmatski izmenjene torako-abdominalne aorte torakalnim stent-graftom. Postoperativni tok protekao je uredno, a bolesnik je otpusten kuci 21. postoperativnog dana. Na kontrolnoj skenerskoj aortografiji, tri meseca nakon izvedene operacije vaskularni status bolesnika bio je uredan sa funkcionalnim visceralnim by pass-evima, urednom pozicijom stent-grafta i bez znacajnog endolika. Zakljucak. Visceralna hibridna rekonstrukcija TAAA tipa III predstavlja komplementarnu hirursku tehniku torakofrenolaparotomijskom pristupu, kompletne otvorene rekonstrukcije TAAA, a da se pri tome ne ugorzava bezbednost bolesnika. Ovaj pristup predstavlja daleko manju traumu za bolesnika, a narocito je znacajan kod bolesnika sa brojnim komorbidnim stanjima, jer nema torakotomije, dok je ishemijskoreperfuziona povreda organizma svedena na minimum, zbog kratkotrajnog prekida cirkulacije kroz aortu u infrarenalnom delu.