DOI:10.2214/AJR.07.3729
AJR 2008; 191:1175-1181
© American Roentgen Ray Society
Endovascular Treatment for Visceral Vessel Complication After Branched Graft Replacement: Initial Results
Ryota Kawasaki1,
Koji Sugimoto1,
Takanori Taniguchi1,
Masato Yamaguchi1,
Masahiko Fujii1,
Kazuro Sugimura1 and
Yutaka Okita2
1 Department of Radiology, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe
650-0017, Japan.
2 Department of Cardiovascular Surgery, Kobe University, Kobe, Japan.
Received January 25, 2008;
accepted after revision April 29, 2008.
Address correspondence to R. Kawasaki
(kawaryo1999{at}yahoo.co.jp).
Abstract
OBJECTIVE. The objective of our study was to retrospectively assess
the safety and efficacy of endovascular treatment for branch stenosis or
obstruction after branched graft replacement in patients with thoracoabdominal
aortic aneurysm or aortic arch aneurysm.
MATERIALS AND METHODS. Seven patients (all men; median age, 62
years; age range, 19–79 years) who had undergone aortic surgery using
branched grafts between March 2004 and January 2007 were treated. Diagnosis
was established on dynamic contrast-enhanced CT or angiography. A self- or
balloon-expandable stent was placed after predilatation with a balloon
catheter and, if necessary, thrombolysis was also performed. Stent patency was
assessed on thin-slice axial images obtained during the arterial phase on
dynamic contrast-enhanced CT.
RESULTS. Seven lesions (one celiac artery, two left subclavian
arteries, and four renal arteries) were treated. The time between the surgery
and treatment was 0–3 days for patients with abdominal lesions and
20–41 days for those with thoracic lesions. Stent placement was
successful in five of the seven patients. In one patient, insertion of the
stent delivery system was unsuccessful; in the other patient, the stent was
not completely expanded. The clinical symptoms and abnormal laboratory data
improved in all patients with successful procedures. No restenosis was
observed on imaging follow-up, with a median patency of 104 days (range,
5–1,218 days) during clinical follow-up (range, 37–1,218 days;
median, 135 days).
CONCLUSION. Endovascular repair can be an alternative treatment for
visceral vessel complications of branched grafts, especially in obstructed but
peripherally patent branches.
Keywords: abdominal aortic aneurysms • branched grafts • endovascular repair • stenosis • stents
Introduction
Endovascular grafting is an advanced technique used to treat thoracic,
aortic, and infrarenal abdominal aortic aneurysms; how ever, surgical repair
is the only feasible treatment for thoracoabdominal aortic aneurysms and
aortic arch aneurysms. Surgical repair of these aneurysms, which requires
reconstruction of the thoracic or abdominal vessel branches, was developed in
the 1950s [1,
2]. Several branch vessel
reconstruction techniques are used currently such as button suturing, in which
the visceral arteries and the surrounding native aortic wall are reattached
directly to an aortic graft in an end-to-side fashion; bypass grafting; and
branched grafting. In 1956, Creech et al.
[3] reported the first
successful case of thoracoabdominal aortic aneurysm repair performed using an
aortic graft with multiple branches. The branched graft must be carefully
orientated to prevent kinking or twisting of the branches
[1]. A graft kink may cause
sudden occlusion of the arterial branch, resulting in end-organ ischemia or
gangrene that may contribute to perioperative mortality.
In several studies, investigators have reported the surgical outcome of
thoracoabdominal aortic aneurysms or aortic arch aneurysms; however, no
description is available regarding the treatment of postoperative kinking of
branched grafts, to our knowledge. Successful endovascular treatment for
thoracoabdominal aortic aneurysm by reconstruction of an obstructed branch
with the button technique has been previously reported
[4]; however, to date,
endovascular treatment for branch stenosis or occlusion after replacement of a
branched graft has not been reported. In this study, we retrospectively
analyzed the initial results of endovascular treatment for visceral vessel
complications after branched graft replacement. To our knowledge, this study
is the first to report an endovascular treatment for this uncommon
condition.
Materials and Methods
Patients
Seven patients (all men; median age, 62 years; range, 19–79 years)
underwent elective surgical repair of chronic dissected aneurysm (four
patients), distal aortic arch aneurysm (one patient), or thoracoabdominal
aortic aneurysm (two patients) between March 2004 and January 2007 with
reconstruction of bilateral renal, celiac, and superior mesenteric arteries
(five patients); brachiocephalic, left common carotid, and left subclavian
arteries (one patient); or only the left subclavian artery (one patient). In
these patients, visceral vessel complications were suspected clinically. In
five patients with abdominal aortic reconstruction, severe liver dysfunction
and elevated levels of aspartate transaminase, alanine transaminase, and
lactate dehydrogenase, which reflect hepatic or other visceral infarctions
(one patient), or oliguria or anuria with an increase in serum creatinine
levels (four patients) developed 0–3 days after surgery. These findings
were observed immediately after surgery and worsened. In two patients with
thoracic reconstructions, dimin ished radial pulsation became evident 13 and
31 days after surgery, although this sign was not ob served during the early
postoperative period.
Diagnoses of a malfunction of graft branches were confirmed with dynamic
contrast-enhanced CT in four patients and angiography in three patients
(Table 1). Dynamic
contrast-enhanced CT showed a total occlusion of the graft branch with a
patent but narrowed anastomosed native artery in three patients (patients 1,
3, and 7 in Tables 1 and
2). In the patient with an
occluded celiac artery and superior mesenteric artery (patient 1), focal
hepatic infarction and total splenic infarction were also detected. In the
remaining one patient, a severe stenosis of a graft branch due to a graft kink
(patient 4) and a narrowed peripheral anastomosed native artery were detected.
After the diagnostic examinations, written informed consent was obtained from
all the patients, their families, or both before patients underwent treatment.
The retrospective review was approved by our institutional review board.
Treatment
Aortography was performed via the femoral artery using a 4-French pigtail
catheter (Royal Flush Plus, Cook), and 3,000–5,000 IU heparin was
infused intraarterially.
In the abdominal lesions, a 6- to 8-French guiding catheter (Vista Brite
Tip, Johnson & Johnson) was used to engage the graft ostium. A 5-French
catheter (S5F-38-70-Typekobe, Clinical Supply) and a 0.035-inch hydrophilic
guidewire (Rajifocus, Terumo) were used for crossing the lesion, but a
0.014-inch microguidewire (Transend, Boston Scientific) and a standard
microcatheter were required in five patients because of difficulty in crossing
the lesion and to prevent visceral vessel injury.
In two patients with occluded branches (patients 1 and 3), a large thrombus
that seemed to be at a high risk for distal embolization was detected while
crossing the lesion. With the permission of the cardiovascular surgeons,
thrombolysis with urokinase was performed in these patients. A tip of a
microcatheter was introduced into the thrombus, and urokinase dissolved with
20 mL of normal saline per 60,000 U was administered with a bolus injection
technique. The location of the catheter tip was corrected during thrombolysis
using several angiograms to check the location of thrombus. The total dose of
urokinase was restricted to 240,000 U because of the health insurance limit in
our country. Stent placement, after predilation with a balloon catheter, was
performed after the clots had completely dissolved.
In the thoracic lesions, 7-French (Goodtech sheath introducer, Goodman) and
5-French (Super sheath, Medikit) introducer sheaths were placed in the femoral
and left brachial arteries, respect ively. The guide wire was then caught
using a 10-mm gooseneck snare (the Amplatz Goose Neck, ev3) after crossing the
lesion with a 4-French catheter (2PB4.2F-38-70-ST, Clinical Supply) and a
0.035-inch hydrophilic guidewire from brachial access. All the procedures,
includ ing pre- and post-dilatation with stent placement, were performed via
femoral access using the pull-through method because the brachial artery in
both patients was too narrow to insert a larger sheath.
The self- or balloon-expandable stents used included the Smart (Johnson
& Johnson Cordis), Wallstent (Boston Scientific), Palmaz (Johnson &
Johnson Cordis), and Palmaz Genesis (Johnson & Johnson Cordis) stents,
based on the operator's preference. By referring to the surgical reports, the
diameter of the stent was kept consistent with that of the graft branches. In
addition to heparin, antico agulative, or antiplatelet drugs, peroral
anticoagulative drugs during and after treatment were not admini stered in all
patients to avoid bleeding.
Follow-Up and Analysis
The patients were followed up during the early postoperative period and
underwent blood examinations and Doppler sonography to evaluate clinical
symptoms. The postoperative images of the treated branches were evaluated with
dynamic contrast-enhanced CT in all five successfully treated patients after
their general condition had improved. Imaging was performed on a 3D 4-MDCT
scanner (Somatom Plus 4, Siemens Medical Solutions). The standard protocol was
as follows: 110 mAseff at 120 kV; slice width, 3 mm; collimation,
2.5 mm; rotation time, 0.5 second; and suspended inspiration. Contrast
material (100 mL, 300 mg I/mL) was injected IV at 3 mL/s through a 22-gauge
catheter. Scans of the area extending from the lung apex to the common femoral
artery were obtained at 30 seconds (arterial phase) and 80 seconds (delayed
phase) after contrast administration.
The projection data were reconstructed in both the phases with a 10-mm
thickness and 10-mm increment. The data in the arterial phase were also
reconstructed with a 3-mm thickness and 2.7-mm increment and were used to
evaluate patency and restenosis. The treated branch was determined as patent
if stenosis of the stent lumen was less than 25%. In the abdominal branches,
we judged the branches as technically patent and the procedure successful when
dynamic contrast-enhanced CT showed well-dilated peripheral vessels on early
phase and normal visceral enhancement on late phase images. In the thoracic
patients, technical success was defined as a difference of within 10 mm Hg of
ipsilateral brachial blood pressure compared with contralateral pressure.
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Fig. 1A —19-year-old man with celiac artery and superior mesenteric
artery (SMA) obstruction (patient 1 in Tables
1 and
2). Inferior mesenteric artery
angiogram reveals SMA and celiac artery obstruction. Proper hepatic artery
displays diffuse narrowing, while SMA is well visualized because of sufficient
blood supply from inferior mesenteric artery.
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Fig. 1B —19-year-old man with celiac artery and superior mesenteric
artery (SMA) obstruction (patient 1 in Tables
1 and
2). Celiac artery angiogram
reveals graft thrombosis. After thrombolysis with urokinase (120,000 U),
lesion was successfully crossed using microguidewire.
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Results
There were nine lesions in seven patients. In patient 1, superior
mesenteric artery obstruction was not treated because the blood supply from
the inferior mesenteric artery was adequate and no symptoms of intestinal
ischemia were observed (Fig.
1A,
1B,
1C). Furthermore, right renal
artery obstruction in patient 5 was excluded from the study because it was
reconstructed using a different anastomotic technique (an inclusion button
technique) resulting in surgical reconstruction with saphenous bypass
grafting. Consequently, seven lesions (one celiac artery, two left subclavian
arteries, and four renal arteries) were indicated to be treated
(Table 2). A total of eight
stents were deployed. No major procedure-related complications such as
anastomotic or graft rupture, bleeding, dissection, or distal embolization
were observed.
Abdominal Branch Lesion
Five patients (patients 1–5; age range, 19–77 years; median
age, 41 years) were treated for abdominal branch lesions. The time be tween
the surgery and diagnosis was 0–3 days. On the same day as the
diagnosis, they were treated on an emergent basis. Stent placement was
successful in three patients. Stent placement failed in patient 2 with a left
renal artery stenosis because of difficulty inserting the delivery system
(Fig. 2A,
2B,
2C). Also, postdilatation was
not successful in patient 2 with left renal artery stenosis because the
proximal edge of the stent protruded into the aortic graft (Fig.
3A,
3B,
3C). In that patient, the serum
creatinine level was persistently elevated. Diagnostic angiography was
performed 31 days after treatment and a total thrombotic occlusion of the
branch was detected. Despite the use of an additional stent and continuous
thrombolysis, reperfusion could not be achieved, thereby resulting in the need
for permanent dialysis.
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Fig. 2A —77-year-old man with left renal artery stenosis and oliguria
(patient 4 in Tables 1 and
2). Left renal artery angiogram
shows stenosis of graft. Balloon dilatation was repeated, but stenosis
recurred due to recoil.
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Fig. 2B —77-year-old man with left renal artery stenosis and oliguria
(patient 4 in Tables 1 and
2). Stent insertion was
attempted, but lesion could not be crossed by delivery system. Thereafter,
several sessions of balloon angioplasty were performed that eventually
resulted in treatment failure.
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Fig. 2C —77-year-old man with left renal artery stenosis and oliguria
(patient 4 in Tables 1 and
2). Contrast-enhanced CT scan
obtained 76 days after treatment shows severe kinking of branch and no
enhancement of left kidney.
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Fig. 3B —41-year-old man with left renal artery stenosis (patient 2 in
Tables 1 and
2). Stent (Wallstent, Boston
Scientific) was placed, but balloon catheter could not be inserted into stent
because of coning at proximal end and protrusion of stent into aortic
graft.
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After treatment, the serum creatinine levels of two patients with renal
artery occlusion (patients 3 and 5) improved or normalized (Fig.
4A,
4B,
4C), although patient 5
underwent temporary dialysis for 11 days. In patient 1, organ dysfunction
immediately improved, although splenectomy was necessary because the
infarction was already shown by preoperative dynamic contrast-enhanced CT. On
follow-up CT in the patient with a celiac artery lesion (patient 1), the area
of focal hepatic infarction that was observed in the lateral segment did not
worsen but diminished slowly accompanying atrophy of lateral inferior segment
of the liver.
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Fig. 4A —51-year-old man with right renal artery obstruction (patient
3 in Tables 1 and
2). Aortogram only reveals
graft branch ostium of right renal arteries. Patient was suffering from
oliguria despite well-depicted left renal artery and parenchyma.
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Fig. 4B —51-year-old man with right renal artery obstruction (patient
3 in Tables 1 and
2). Right renal angiogram
obtained after crossing lesion with microguidewire reveals that peripheral
blood flow was maintained by renal capsular artery.
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Fig. 4C —51-year-old man with right renal artery obstruction (patient
3 in Tables 1 and
2). Final angiogram after
balloon-expandable stent deployment via left brachial artery reveals restored
blood flow.
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Thoracic Branch Lesion
Two patients (patients 6 and 7; 79 and 62 years, respectively; median age,
70.5 years) were treated (Fig.
5A,
5B,
5C,
5D). The time between surgery
and clinical diagnosis was 13 and 31 days and they were treated electively.
The time between the clinical diagnosis and treatment was 7 and 10 days. Stent
placement was successful in these two patients, and diminished left brachial
blood pressure immediately normalized. There were no clinical symptoms of
cerebral infarction.
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Fig. 5B —79-year-old man with left subclavian artery obstruction and
left arm ischemia (patient 6 in Tables
1 and
2). Crossing lesion was
difficult via femoral access but was successful via brachial access.
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Fig. 5C —79-year-old man with left subclavian artery obstruction and
left arm ischemia (patient 6 in Tables
1 and
2). Balloon-expandable stent
was placed via femoral access using pull-through method. Residual stenosis was
observed in proximal portion.
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Fig. 5D —79-year-old man with left subclavian artery obstruction and
left arm ischemia (patient 6 in Tables
1 and
2). Additional stent was
deployed via brachial access because delivery system could not be easily
inserted to cross stenosis.
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Consequently, technical success was achieved in five of the seven patients
(71.4%). When restricted to obstructed vessels, technical success was 100%
(5/5). Patients were clinically followed for 37–1,218 days (median, 135
days). One patient (patient 4) died while in the hospital; in that patient,
the stent could not be deployed owing to Serratia pneumonia unrelated
to the procedures. The median patency interval was 104 days (range,
5–1,218 days) in five patients. All the treated vessels were patent and
only one obstruction was detected on dynamic contrast-enhanced CT in one
patient with thrombotic obstruction.
Discussion
The button suturing method, which is a traditional technique for
reconstruction of visceral vessel branches, has several problems during
surgery and long-term follow-up. The visceral arteries with aortic aneurysms
often have atherosclerotic occlusive disease. In such situations, visceral
endarterectomy is required during aneurysm repair, which can cause vessel
thrombosis or perforation because of the fragile vessel wall. Moreover, this
technique increases the risk of subsequent patch aneurysms developing, which
is considered to be one of the late complications of the button suturing
technique, with a reported prevalence of 3–20%
[1–3,
5–7].
Branched grafting enables direct suturing of the normal vessels to the
branches of the graft, thereby minimizing those risks.
On the other hand, branched grafts rarely kink or twist when the
anastomosed viscera are returned to their anatomic position. The reported
incidence of visceral artery occlusion in button suturing, bypass grafting, or
endarterectomy is 1.2–3.5%
[8–11]
in the early postoperative period and 4.8%
[9] in the later periods. To
our knowledge, no such complications have been reported in visceral vessel
branches.
The diagnosis of a visceral vessel complication in cases of intestinal or
aortic arch branch lesions is relatively easy. In contrast, it is difficult to
confirm renal artery lesions because postoperative renal dysfunction or acute
renal failure, which is associated with high early and late mortality rates
[12–15],
occurs in 3.1–22% of patients with thoracoabdominal aortic aneurysm or
abdominal aortic aneurysm replacements
[9,
15–17]
and in 3.3–12% of patients with aortic arch replacements
[18–22].
Doppler sonography is a less invasive method but may often fail to establish
the diagnosis. Dynamic contrast-enhanced CT is the best option, although the
contrast material used may adversely affect renal function. Dynamic
contrast-enhanced CT provides information such as the location of the graft
ostium, degree of kinking, and presence or absence of peripheral blood flow
and distal or proximal thrombus. Rigorous analysis will facilitate the
detection of potential lesions and administration of early treatment.
Patent collateral arteries (i.e., renal capsular, gastroduodenal, and left
common carotid arteries) have difficulty maintaining peripheral arterial blood
flow. Hence, if the collateral arteries are absent or occluded, the peripheral
arteries will develop complete thrombosis, resulting in an organ infarction
and treatment failure. In left renal artery occlusion (as seen in patient 4 in
our study) particularly, the renal capsular and patent peripheral renal
arteries, which could not be observed on the aortogram, could be clearly
detected on dynamic contrast-enhanced CT. Evaluation of the peripheral blood
supply using dynamic contrast-enhanced CT before treatment may also contribute
to improving the success rate and may help to identify cases needing surgical
or endovascular treatment.
Surgical correction is a preferred choice of treatment. However, it
increases the risk of mortality and morbidity because hemodynamic instability
and perioperative bleeding during redo surgery may further worsen organ
ischemia. Endovascular treatment is an alternative and less invasive treatment
method in patients with such complications. Only one successful endovascular
treatment of an occluded solitary renal artery that was reconstructed with the
button technique has been reported
[4]. In contrast, there are no
articles in the literature regarding visceral vessel complications in a
branched graft. To our knowledge, our study is the first and largest reported
series of endovascular treatment in patients with visceral vessel
complications of branched grafts.
The contralateral renal artery was patent in three patients in our series.
Whether an occluded renal artery should be treated when a contralateral renal
artery is patent is controversial. It is difficult to predict whether the
contralateral kidney can compensate for the function of the other kidney. In
previous studies, investigators have reported that postoperative renal failure
or temporary dialysis in thoracoabdominal aortic aneurysms can be a
significant predictor for early death
[11,
15]. Moreover, renal ischemic
time also influences the recovery of renal function. Therefore, our present
strategy is that treatment should be considered as soon as possible when
oliguria is evident and the occlusion of graft branches and patent peripheral
vessels are seen on imaging studies.
Our study also included patients with only stenosis of the renal artery. It
is also controversial whether the treatment is necessary or not in patients
with a patent contralateral renal artery. However, differential diagnosis is
most difficult whether oliguria is due to decreased arterial blood flow in
affected renal artery or to common postoperative change mentioned above.
Differential diagnosis is most difficult whether oliguria is due to decreased
arterial blood flow or to common postoperative change mentioned earlier.
Moreover, definitive criteria for treatment, such as the degree of stenosis or
the pressure gradient, are not present in acute stenosis of visceral arteries.
In the acute phase, whether stenosed branches will recover renal function or
subsequently become occluded is also impossible to predict. Stenosed branches
were treated in our study group, but close follow-up should also be considered
for differentiation if the cause of renal dysfunction is due to diminished
renal arterial blood flow or postoperative change. In addition, more detailed
data, such as the percentage of stenosis, the pressure gradient, or a split
renal function test using radioisotopes before treatment, are crucial for
determining the indication in stenosed arteries. Nevertheless, our results
show the feasibility of endovascular treatment for visceral vessel
complications, especially obstructions, in patients with a branched graft
replacement. Of course, surgical backup is mandatory because there is also a
risk of bleeding due to thrombolysis with urokinase or anastomotic or graft
rupture after balloon dilatation or stent placement.
The main limitations of our study are the small sample size and the
insufficient evaluation of long-term patency. Although there was no restenosis
in patients with successful treatment during this study's follow-up period,
which ranged from approximately 1 month to 3.3 years, not all patients were
followed up for a sufficient amount of time to determine the long-term
restenosis rate compared with that of visceral vessel stent placement in
atherosclerotic diseases. In addition, anticoagulative drugs were given to
some patients after treatment in our series, which may have influenced our
study results. A longer follow-up period in a larger sample of patients would
improve evidence for the efficacy of this treatment.
In conclusion, the results of our study show the feasibility of
endovascular repair as the first choice of treatment for branched graft
occlusion or stenosis. No restenosis in successfully treated patients was
observed during follow-up of up to 3 years, but long-term patency was not
observed in this study. In addition, the indication for graft stenosis is
unknown. Further follow-up in a larger number of patients is needed to build
evidence for the long-term efficacy of endovascular repair.
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Abstract
Introduction
