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Thoracic aortic stent grafting in patients with connective tissue disorders: a word of caution
Siamak Mohammadi1, Jean-Pierre Normand, Pierre Voisine
1Department of Cardiac Surgery and Radiology, Laval Hospital, Québec city, Québec, Canada.
Insights
Thoracic stent-grafts in patients with connective tissue disorders (CTD) are associated with significant complications. Researchers suggest stent-graft use in CTD aortas is a relative contraindication due to high risks.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Genetics
Background:
- Connective tissue disorders (CTD) present unique challenges for thoracic stent-graft repair.
- Limited data exists on the efficacy and safety of thoracic stent-grafts in CTD patients.
Purpose of the Study:
- To report outcomes of thoracic stent-graft placement in three patients with connective tissue disorders.
- To evaluate the safety and efficacy of thoracic stent-grafts in this high-risk population.
Main Methods:
- Case series describing three patients with Marfan syndrome and Ehlers-Danlos syndrome undergoing thoracic stent-graft procedures.
- Detailed review of imaging (CT) and clinical outcomes, including complications and management strategies.
Main Results:
- Complications included false aneurysms, intramural hematoma, aortic dissection, and endoleaks.
- One patient required explantation and re-replacement of the descending aorta due to complications.
Conclusions:
- Thoracic stent-graft deployment in native CTD-affected aortas is associated with significant complications.
- Stent-graft use in CTD aortas should be considered a relative contraindication.
- Alternative strategies with minimal radial force and oversizing are recommended for high-risk cases.
Objective:
: Use of thoracic Stent-graft in patients with connective tissue disorders (CTD) remains limited. We herein report 3 patients with CTD who underwent stent grafting.
Methods And Results:
: Case 1; A male Marfan patient was operated for thoraco-abdominal aneurysm. On computed tomography (CT), large false aneurysm at the proximal anastomosis was documented which was excluded with a 30 mm Talent stent-graft with 10-15% oversize. Case 2; A female with Ehlers-Danlos syndrome had undergone resection of descending aortic thoracic aneurysm presented with an enlarging aneurysm distal to the graft. Three Talent stent-grafts (15% oversize) were deployed with balloon dilatation to exclude the aneurysm. The immediate postoperative period was complicated by an extensive intramural hematoma of the descending aorta with hemothorax, managed conservatively. Case 3; A female Marfan patient had undergone Bentall procedure and mitral repair followed with resection of the proximal descending aorta. Three months later a false aneurysm at the distal anastomosis was treated with a 24 mm Valiant stent-graft (30% oversize). Aortic dissection distal to stent was documented on the early postoperative CT. The dissected aneurysm enlarged significantly with a type I distal endoleak during follow-up. Concomitantly, the patient presented a class III dyspnea owing to a severe mitral regurgitation. The patient underwent a successful MVR and stent-graft explantation with replacement of the descending aorta.
Conclusion:
: Significant complications supervened when stent-grafts were deployed in native aorta. We thus recommend that deploying a stent-graft in a CTD diseased aorta should be considered a relative contraindication. In cases with prohibitive or high risk surgery, use of a stent-graft with minimal radial force and minimal oversizing without balloon dilatation should be considered.
