Colonic Stent-Assisted Endoluminal Embolization in the Aortic Arch

Abstract

Extended aortic arch repair using a prefabricated multibranched Dacron graft has been a standard method to reconstruct the aortic arch for complex aortic dissections. Late complications associated with a Dacron graft or its suture lines in the absence of infection are rare. We report a case of a ligated Dacron branch blowout in a patient with Loeys-Dietz syndrome with previous reoperative aortic arch reconstructions. This pathologic process posed unique challenges to endovascular therapy because of the wide, short stump without a neck and the proximity to adjacent head vessels. This patient was successfully treated with off-label colonic stent-assisted endoluminal embolization in the aortic arch.

Figure 1

Computed tomography angiography (CTA) image at presentation. (A) CTA image with massive perigraft hematoma and extravasation from the blown out stump. (B) Implanted prefabricated multibranched Dacron graft (Siena collared graft; Vascutek Terumo) was oriented in the same way as the CTA image with 3-dimensional reconstruction. (C) CTA image with 3-dimensional reconstruction, visualizing the relationship between the blown out stump and other head vessels within the aortic arch.

Figure 2

Colonic stent and intraoperative fluoroscopy image. (A) Enteral colonic stent (WallFlex colonic stent; Boston Scientific) has favorable features to support the endoluminal embolization procedure within the aortic arch, including uncoverability of the head vessels (bare-metal stents), self-expandable feature, recapturability, and relatively large caliber (flare diameter of 30 mm, stent body diameter of 25 mm, expanded stent length of 60 mm). (B) The implanted prefabricated multibranched Dacron graft during the original surgical procedure with simulation of colonic stent insertion. The relationship between the blown out limb for perfusion and the other 3 limbs for head vessels is well shown in this picture. (C) Intraoperative fluoroscopy image with fully deployed colonic stent (arrow) within the original Dacron graft and frozen elephant trunk. The angled catheter was positioned through the stent interstices, and the endoluminal coil release was well supported by the colonic stent.

Figure 3

Preoperative and 1-year follow-up computed tomography angiography (CTA) images. (A) Preoperative CTA image with massive perigraft hematoma and extravasation from the blown out stump. (B) CTA image at 1-year follow-up at the same level demonstrating complete resolution of the mediastinal hematoma. (C) Sagittal image with colonic stent and endoluminal coils (arrow) located within the aortic arch.