Two-Stage Endovascular Repair for Concurrent Penetrating Atherosclerotic Ulcers of the Thoracic and Abdominal Aorta
A 66-year-old man was transferred to our hospital for the treatment of two asymptomatic saccular aneurysms caused by a penetrating atherosclerotic ulcer in the descending thoracic aorta and the infrarenal abdominal aorta. All of the laboratory data were within normal range except serum creatinine. The level of serum creatinine was slightly high at 1.5 mg/dL. A computerized tomography (CT) scan demonstrated that a saccular aneurysm measuring 60 mm in the longest diameter in the descending thoracic aorta was at the level of the 9th thoracic vertebra, and the other saccular aneurysm measuring 55 mm in the longest diameter in the infrarenal abdominal aorta was at the level of the 3rd lumbar vertebra (). We decided to perform staged endovascular repair on this patient in order to prevent contrast-induced nephropathy by reducing the total amount of contrast material administered, and to prevent paraplegia that could occur if the long segment of the aorta were covered with a stent graft in one session. In addition, we tried to avoid the risk of rupture while waiting for the second endovascular procedure by decreasing the interval time between the staged procedures.\nDuring the first stage, a 34×100 mm stent-graft, a self-expandable custom-made type (S&G Biotech Inc., Seongnam, Korea), was deployed along the thoracic saccular aneurysm and spinal fluid drainage was performed to prevent paraplegia. Additional 36×80 mm stent-graft was used because of a wind-sock effect (). During this procedure, 200 mL of nonionic and iso-osmolar contrast medium iodixanol (Visipaque; Nycomed Imaging AS, Oslo, Norway) was used. In the second stage, one month later, Zenith stent-grafts (Cook Inc., Minneapolis, MN, USA) were placed from the saccular abdominal aneurysm to both common iliac arteries, thereby excluding the aneurysm from circulation. During this second stage, 240 mL of iodixanol (Visipaque, Nycomed Imaging AS) was used. Perioperative cerebrospinal fluid drainage was performed to prevent spinal cord ischemia (SCI). The patient presented no perioperative deterioration of renal function or paraplegia. A ten-month follow-up CT angiogram showed both stent-grafts were patent with no evidence of thrombus, endoleak, aneurysm growth, or complications derived from the procedure (). Two-stage endovascular repair may therefore be used to successfully treat separate saccular thoracic and abdominal aortic aneurysms without any deterioration of renal function or paraplegia.