online a

1500 • Letters to the Editor November 2009 JVIR

tomography showed marked accumulation of [18F]fluoro-deoxyglucose in the consolidation. The consolidation wasdeemed to be a local progression and CT-guided cuttingneedle biopsy was performed. The biopsy specimensmainly consisted of necrotic tissue in which there were anumber of Aspergillus hyphae (Fig, d); no viable cancertissue was found. The value of serum �-D-glucan wasnormal (�6.0 pg/mL; normal range, �11.0 pg/mL); se-rum Aspergillus antigen was negative. Since then, the pa-tient has been receiving voriconazole (Vfend; Pfizer, NewYork, New York). Positron emission tomography per-formed at the latest follow-up (5 months after the initia-tion of the therapy for aspergilloma) revealed shrinkageof consolidation and decreased accumulation of [18F]flu-orodeoxyglucose.

Okuma et al (3) reported cavity formation at a fre-quency of 14% (14 of 100 sessions) at an average of 1.5months after RF ablation for lung cancer. Cavitation oc-curred more frequently in patients who had a lesion nearthe chest wall, lung cancers as the primary lesion, andpulmonary emphysema (3). In our case, a large cavity wasformed after a total of three RF ablation sessions carriedout for metastasis near the chest wall from primary lungcancer. Pulmonary aspergilloma is an Aspergillus infectionthat occurs in patients with preexisting cystic or cavitarylung disease. Residual cavities after tuberculosis are mostcommonly infected with Aspergillus species (4). Other con-ditions predisposing to aspergilloma include sarcoidosis,bronchiectasis, and pulmonary fibrosis (4). The presentcase suggests that a cavity formed after RF ablation forlung cancer may also be a scaffold for aspergilloma.Therefore, the possibility of aspergilloma should be con-sidered in the case of consolidation formed in a cavityafter RF ablation, and it should be differentiated fromlocal tumor progression.

References1. Lencioni R, Crocetti L, Cioni R, et al. Response to radiofre-

quency ablation of pulmonary tumours: a prospective, intention-to-treat, multicentre clinical trial (the RAPTURE study). LancetOncol 2008; 9:621–628.

2. Hiraki T, Gobara H, Iishi T, et al. Percutaneous radiofrequencyablation for clinical stage I non-small cell lung cancer: results in

Figure. (a) CT image before RF ablation shows a tumor measuafter the third RF ablation shows a large thin-walled cavity (arroRF ablation reveals consolidation (arrow) in the ablation zone. (stain, original magnification �40). (Part d is available in color

20 nonsurgical candidates. J Thorac Cardiovasc Surg 2007; 134:1306–1312.

3. Okuma T, Matsuoka T, Yamamoto A, et al. Factors contributingto cavitation after CT-guided percutaneous radiofrequency abla-tion for lung tumors. J Vasc Interv Radiol 2007; 18:399–404.

4. Roberts CM, Citron KM, Strickland B. Intrathoracic aspergilloma:role of CT in diagnosis and treatment. Radiology 1987; 165:123–128.

Endovascular Repair of a Distal Aortic ArchPseudoaneurysm with Use of a Scallop-edgedStent-graft

From: Qingsheng Lu, MD, PhD, Zaiping Jing, PhD,Junmin Bao, MD, PhD, Yifei Pei, MD

Department of Vascular SurgeryChanghai HospitalSecond Military Medical UniversityNo. 168 Changhai Rd.Shanghai, China 200433

Editor:Pseudoaneurysm of the aortic arch is an unusual compli-

cation of arch vessel bypass and poses a complex surgicalchallenge. Operative management may involve open thora-cotomy, cardiopulmonary bypass, and aortic arch repair, allof which carry significant morbidity and mortality. LeMaireet al (1) analyzed 1,220 consecutive patients undergoingthoracoabdominal aortic aneurysm repair via multiple logis-tic regression with stepwise model selection. The resultshowed that 58 patients (4.8%) died within 30 days and 56patients (4.6%) developed paraplegia or paraparesis (1). Al-though some series of stent-graft treatment of the descend-ing thoracic aorta have been reported, fewer cases of aorticarch stent-graft treatment have been attempted becasue ofthe anatomic difficulties posed by the presence of brachio-cephalic vasculature, arch curvature, and the absence ofadequate stent-graft landing zones. Herein, we present anunusual case of aortic pseudoaneurysm involving the distalarch treated successfully with the use of a scalloped stent-

None of the authors have identified a conflict of interest.

(arrow) in the left upper lobe. (b) CT image obtained 1 monthe ablation zone. (c) CT image obtained 8 months after the thirdiopsy specimen shows a number of Aspergillus hyphae (Grocottt www.jvir.org.)

ring 2 cmw) in th

d) The b

DOI: 10.1016/j.jvir.2009.07.037

h vessels

Letters to the Editor • 1501Volume 20 Number 11

graft. The work is in accordance with principles of theDeclaration of Helsinki.

A 45-year-old woman presented with a grossly abnormal

Figure. (a) CT scan shows the presence of a 7.5-cm thoracic aortarch and descending aorta. The origin of the LSA is 9 mm proximaproximal neck. (b) The scalloped portion of uncovered stent was mopposite the origin of the LSA and the posterior pedicle screw fixexclusion of the pseudoaneurysm and satisfactory flow in the arc

mediastinal silhouette, with widening on the chest radio-

graph suggestive of a thoracic aortic aneurysm. One yearearlier, the patient was incolved in an accident that resultedin thoracic vertebrae fracture, which led to paraplegia and

oaneurysm positioned on the inner curve of the junction of aorticproximal neck and the origin of the LCCA is 2 cm proximal to thethe tube stent-graft. (c) Angiography shows the pseudoaneurysmr thoracic vertebral fractures. (d) Completion angiography shows. (Available in color online at www.jvir.org.)

ic pseudl to theade in

ation fo

posterior pedicle screw fixation of T1–T4. A computed to-

1502 • Letters to the Editor November 2009 JVIR

mographic (CT) scan confirmed the presence of a 7.5-cmthoracic aortic pseudoaneurysm positioned on the innercurve of the junction of the aortic arch and the descendingaorta, opposite the origin of the left subclavian artery (LSA;Figure, a). The outer curve was not involved. The left ver-tebral artery was an ascendant artery and was larger thanthe right. The screws were close to but not in direct contactwith the pseudoaneurysm. The patient declined open repairin view of the morbidity of the procedure.

CT also showed the ostium of the LSA 9 mm proximal tothe proximal neck of the aneurysm and the ostium of the leftcommon carotid artery (LCCA) 2 cm proximal to the prox-imal neck of the aneurysm. Use of a standard, nonfenes-trated stent graft would have necessitated occlusion of theostia of the LSA and LCCA to obtain fixation. To avoid thisproblem, a Relay stent-graft (Bolton Medical, Sunrise, Flor-ida) was manufactured so that a scalloped portion of uncov-ered stent would extend over the LCCA and LSA ostia topreserve perfusion. Because the diameter of the distal archwas 28 mm, we chose a 32-mm � 150-mm tube stent-graft.The scalloped portion was made 20 mm � 20 mm with theexpectation that no rotation would be possible during de-ployment (Figure, b). The margins of the scallop weremarked with radiopaque markers to aid correct positioning.

A right iliac conduit graft was constructed for accessbecause both common femoral arteries were relatively nar-row. A pigtail catheter was passed from the left brachialartery and positioned adjacent to the ascending aorta forangiography and for marking the LSA. The other pigtailcalibrated angiography catheter with radiopaque markerswas passed from the right iliac conduit and also was posi-tioned adjacent to the ascending aorta for angiography andmeasurement. Angiography was performed for reassess-ment and for confirmation of the size of the stent-graft. Weadjusted the direction of the x ray (left anterior oblique 43°)and spread the branches of the arch out fully and clearly(Figure, c). Through the second catheter, a 0.035-inch Lun-derquist Super Stiff wire (Cook Australia, Brisbane, Austra-lia) was deployed with the floppy tip looped back to preventaortic valve injury. The customized fenestrated tube stent-graft was positioned and deployed so the marker at the baseof the scallop was adjacent to the left edge of the LSA. Therewas relative hypotension at this time (60–70 mm Hg sys-tolic) with administration of urapidil hydrochloride injec-tion combined with esmolol hydrochloride injection.

Completion angiography showed exclusion of the pseu-doaneurysm and satisfactory flow in the arch vessels; thestent-implanted graft was well positioned so the fenestrationpreserved flow to the LSA and LCCA (Figure, d). A CT scanperformed before discharge showed exclusion of the pseu-doaneurysm and patency of the LSA and LCCA. The patientwas discharged without any complications on postoperativeday 7.

At 12 months after treatment, the patient remains well. ACT scan performed at this time showed that the aneurysmremains excluded with a decrease in size of the residual sacto a maximum of 5.4 cm, and that the LSA and LCCA werepatent without ostial stenosis.

Endovascular repair of an aortic arch aneurysm neces-

sitates covering one or all of the great vessels of the archto provide an adequate neck for graft implantation andstability (2). Intentional LSA occlusion in this setting hasbeen reported by many groups, but carries the risk ofstroke and ischemia of the left upper limb (3). Hybridoperations with reconstruction of the LSA and LCCAhave been described for safeguarding perfusion of thesebranches but requires more complex procedures, whichmay become invasive and lead to complications (3). Anew technique of in situ stent-graft fenestration to pre-serve the LSA has been reported (4), but there are uncer-tainties regarding the long-term stability of the fabrictears that are an inherent part of this technique.

In this patient, we elected to create a scalloped portionof bare stent in a commercial stent-graft to maintain flowto the LSA and LCCA, thereby providing adequate stent-graft fixation and pseudoaneurysm exclusion by the cov-ered portion of the stent on the inner aspect of the curve.Four procedures were adopted to enable correct proximalplacement without covering the ostia. The first procedurewas adjustment of the direction of the x ray to locateprecisely the ostia of the LSA and LCCA at the tangent ofthe outer curve of the arch, and to spread the branches outfully and clearly. The second procedure was placement ofa catheter through the LSA to mark this branch. The thirdprocedure was the placement of two silver markers atopposite sides of the top of the scallop and one marker atthe bottom of the scallop. The fourth procedure was par-tial expansion of the device to ascertain the correct posi-tion of the scallop before full expansion.

Completion angiography showed complete exclusion ofthe pseudoaneurysm without any endoleak. Consequently,we did not use a balloon to mold the stent-graft, and wethereby avoided the temporary interruption of circulationand blood flow in the LCCA and LSA (5).

In conclusion, the use of an uncovered (ie, scalloped) orfenestrated graft may be an effective and safe technique tosuccessfully treat aortic arch pseudoaneurysms. If patientsare appropriately selected, the relative flexibility of the de-sign allows for conformation to the arch curvature withoutendoleaks, and the radial force of the stent promotes appo-sition at the landing zones.

References1. LeMaire SA, Miller CC, Conklin LD. Estimating group mortal-

ity and paraplegia rates after thoracoabdominal aortic aneurysmrepair. Ann Thorac Surg 2003; 75:508–513.

2. Melissano G, Civilini E, Bertoglio L, Setacci F, Chiesa R.Endovascular treatment of aortic arch aneurysms. Eur J VascEndovasc Surg 2005; 29:131–138.

3. Kurimoto Y, Ito T, Harada R, et al. Management of left subcla-vian artery in endovascular stent-grafting for distal aortic archdisease. Circ J 2008; 72:449–453.

4. McWilliams RG, Murphy M, Hartley D, Lawrence-Brown MM,Harris PL. In situ stent-graft fenestration to preserve the leftsubclavian artery. J Endovasc Ther 2004; 11:170–174.

5. Criado FJ, Barnatan MF, Rizk Y, et al. Technical strategies toexpand stent-graft applicability in the aortic arch and proximaldescending thoracic aorta. J Endovasc Ther 2002; 9(suppl II):S32–

S38.