Revised Endografting for a Giant Descending Thoracic Aorta Aneurysm due to Synchronous Type III/Ib Endoleak, Causing...

Although surgical resection and graft replacement therapy for thoracic aortic aneurysms has advanced greatly over the last 20 years, significant perioperative morbidity and mortality still occur, particularly in patients considered high risk due to significant coexisting medical illness or previous operations performed for the treatment of intrathoracic disease.

The case described is that of a patient with a giant (13.8 cm) symptomatic descending thoracic aorta aneurysm (DTAA), previously treated endovascularly 15 years ago. The expanding aneurysm was due to undiagnosed synchronous type III/Ib endoleak resulting in chronic malnutrition and eventually dysphagia and dyspnea due to compressive symptoms of the esophagus. Besides the risk of rupture, dyspnea and dysphagia with progressive weight loss were significant indications necessitating repair. Regarding his major comorbidities, the patient was identified as high risk for open surgical repair, therefore an endovascular option was offered. Two valiant tube endografts were inserted and deployed successfully without complications.

Postoperatively, upper gastrointestinal endoscopy imaging that was performed to the patient revealed marked persistent stenosis of the esophagus despite aneurysm pressure relief. However, at the multidisciplinary team meeting, an esophageal stenting was ruled out due to the risk of stent fracture and esophageal perforation with its devastating complications. Therefore, a conservative management was deemed appropriate for the patient taking into consideration the risks of prolonged hospitalization and malnourishment coupled with an unpredictable clinical course regarding the remission of the symptoms. Despite the slight gradual clinical improvement in the immediate postoperative period, the patient passed away at the 40th postoperative day due to hospital acquired pneumonia.

Following endovascular repair of giant DTAA compressing the esophagus, significant symptomatic improvement should not be always expected due to the large residual thrombotic aneurysm sac. Although compression symptoms can be managed conservatively in patients deemed at high risk for esophageal perforation, postoperative course and management is of paramount importance and should be treated on an individual basis.