- Elephant Trunk
-Protects the diseased descending thoracic aorta until the second segment of the surgery can be performed
-Used as part of the descending aortic graft at second surgery
-Enables second surgery to be performed distal to first surgical location, in unaltered tissue planes - Extensive Aortic Pathology
Stage 1:
-Ascending aortic graft
-Elephant trunk prosthesis arch/proximal descending thoracic aorta
Stage 2:
-Descending aorta +/- abdominal aorta repair - Extensive Aortic Pathology
Aneurysm, dissection or other surgical pathology that involves
-ascending aorta
-aortic arch
-descending
-+/- abdominal aorta
Necessitates staged repair - Complications of Stent Placement
-Incomplete Apposition
-Endoleak
-Vascular Occlusion
-Stent Migration
-Dissection - Post Stent Placement
-Aneurysm sac decreases in size progressively
--Lack of regression or increase in size reflects underlying endoleak
-Evaluate branch vessels for compromise
-Change in stent positioning - Thoracic Endovascular Stents: Endoleaks
- Type I: these result from incomplete seal of the ends of the stent to the aortic wall
- Type II: result from retrograde flow of blood into excluded lumen from patent branch vessels of the aorta
- Type III: result from junctional dehiscence or device degeneration
- Type IV: result from porosity of the stent
- Type V: are increase in size of excluded lumen w/o enhancement in excluded lumen - Thoracic Endovascular Stents: Endoleaks
- Occur in up to 29% of cases
- Five types of endoleaks occur
- Type I account for 40% of all endoleaks
- Thoracic Endovascular Stents: Complications
- Collapse of stent
- Migration of stent
- Endoleak
- Pseudoaneurysm or dissection
- Pulmonary embolism
- Thoracic Endovascular Stents:Indications
- Aortic aneurysms
- Acute and chronic dissection
- Penetrating ulcer
- Intramural hematoma
- Traumatic aortic rupture
- Complications of Endovascular Stent Placement
- Endoleaks
- Stent migration
- Pseudoaneurysms
- Dissection
- Aortic perforation
- Kinking
- Thrombosis
- Coverage of key arch vessels
"Postprocedure multidetector CT is mandatory to assess stent placement, efficacy, and complications. Important factors to document are location of the stent, stent patency, size of the aorta, thrombosis of disease outside the aortic lumen, and any complications."
Thoracic Aortic Stent-Grafts: Utility of Multidetector CT for Pre- and Postprocedure Evaluation
Bean MJ, Johnson PT, Roseborough GS, Black JH, Fishman EK
RadioGraphics2008; 28:1835-1851
"In this article, we discuss which patients are potential candidates for thoracic aortic stent graft placement and demonstrate how multidetector computed tomography with two dimensional multiplanar reformation (MPR) and three dimensional rendering (3D) is relevant in preoperative imaging and post operative assessment of thoracic stent grafts."
Thoracic Aortic Stent-Grafts: Utility of Multidetector CT for Pre- and Postprocedure Evaluation
Bean MJ, Johnson PT, Roseborough GS, Black JH, Fishman EK
RadioGraphics2008; 28:1835-1851
- Thoracic Endovascular Stent Placement: Patient Selection
- Penetrating ulcers
- Aortic aneurysm
- Aortic dissection
- Acute traumatic aortic injury
- Aortic coarctation
- Thoracic Aneurysm Repair in Elderly Patients: Complications
- Mortality rate is 7-12% in elective cases
- Mortality is up to 40% in elective cases
- CTA and Thoracic Stent Grafts
- Pre-operative planning
- Post-operative assessment
- Endoleak Graft movement or fracture
- Size of native aorta
"Potential complications of endovascular stent placement include endoleaks, stent migration, pseudoaneurysms, dissection, aortic perforation, kinking, thrombosis, and coverage of vital branch vessels." Thoracic Aortic Stent-Grafts: Utility of Multidetector CT for Pre- and Postprocedure Evaluation Bean MJ, Johnson PT, Roseborough GS, Black JH, Fishman EK RadioGraphics 2008; 28:1835-1851
- Endovascular Stent Placement: Applications
- Penetrating ulcers
- Aortic dissection
- Aortic aneurysms
- Aortic rupture
- Congenital abnormalities
- Endovascular Stent Placement: Complications
- Endoleaks
- Stent migration
- Pseudoaneurysms
- Dissection
- Aortic perforation
- Kinking
- Thrombosis
- Coverage of vital branch vessels
- "The combination of arterial enhanced phase and unenhanced imaging performed at 1-month follow-up offers improved specificity and positive predictive values compared with arterial phase images alone. Delayed phase imaging does not significantly increase sensitivity for detection of endoleaks, but it does depict low flow endoleaks not seen on arterial enhanced phase."
Iezzi R et al. Radiology 2006;241:915-921.
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