Emergent Endovascular Stent Grafts for Ruptured Aortic Aneurysms

Abstract

Ruptured aortic aneurysms uniformly require emergent attention. Historically, urgent surgical repair or medical management was the only treatment options. The development of covered stent grafts has introduced a third approach in the care of these critical patients. The clinical status of the patient and local physician expertise drive the treatment modalities in the majority of cases. The goal of therapy in these patients is to stabilize the patient as quickly as possible, establish maximum survival with minimum morbidity, and provide a long lasting result. The endovascular approach has become an acceptable treatment option in an increasing number of patients presenting with ruptured aneurysmal disease of both the descending thoracic and abdominal aorta. Major factors influencing treatment include patient clinical status, characteristics of the aorta, physician preference, institutional experience, and availability of appropriate equipment. Planning, experience, and the ability to improvise effective solutions are keys to the success of the procedure when endovascular techniques are utilized. Three separate cases, requiring intraprocedural improvisation, are presented followed by a review of the literature.

Keywords: EVAR; TEVAR; emergent stent graft; interventional radiology; ruptured aneurysm.

Fig. 1

Computed tomographic image of the first patient's ruptured abdominal aortic aneurysm. Note the high attenuation fluid and stranding in the retroperitoneal fat (arrow).

Fig. 2

Computed tomographic image of the second patient's ruptured internal iliac artery aneurysm. There is high attenuation fluid adjacent to the dilated artery (arrow).

Fig. 3

Contrast-enhanced computed tomographic image of the third patient's disrupted Dacron graft. Evidence of acute hemorrhage includes the mediastinal fat stranding, bilateral pleural infiltrates (due to communication with the bronchial tree), and high attenuation pleural fluid.

Fig. 4

Algorithm (a) initiates the evaluation of the patient with a suspected rupture by determining if the patient is clinically stable enough to undergo evaluation for an endograft. Algorithm (b) determines if the patient is an operative candidate. These initial choices in the decision tree impart opposite biases into the survival curves for endograft and open surgical operation, defining one hospital's treatment protocol. Note the initial question in the decision tree can lead to selection bias.

Fig. 5

Pelvic arteriogram demonstrating a left external iliac arterial occlusion. The aortogram (a) demonstrates the patent left common and internal iliac arteries. Selective injection from a left common femoral approach (b) demonstrates the distal aspect of the external iliac artery occlusion (arrow) (as well as the left hip arthroplasty). An aorto-uni-iliac device in this patient would have likely resulted in significant buttock claudication. Extravascular and subintimal techniques were used in the occluded segment, allowing placement of a bifurcated abdominal aortic endograft device and preserving arterial flow into the left hemipelvis. Aortogram after repair (c) demonstrates continued perfusion through the left internal iliac artery (arrow) as well as contrast within the sheath in the subintimal space along the left external iliac artery.

Fig. 6

Arteriogram of the second patient's repaired aortoiliac aneurysm, demonstrating flow through the endograft, and occlusive coils in the anterior and posterior divisions of the left internal iliac artery (arrows).

Fig. 7

Arteriogram (a) demonstrates the large contained rupture in the descending thoracic aorta (open black arrow) as well as the initial stent graft deployment forming the seal at the proximal landing zone (solid white arrow). Arteriogram (b) demonstrates the exclusion of the aortic defect after placement of the second stent bridging the proximal landing zone with sufficient overlap into the distal stent graft. Poststenting computed tomography (c) demonstrates the excluded aortic injury as well as the initial open surgical graft material (arrow).