Off-label use of thoracic aortic endovascular stent grafts to simplify difficult resections and procedures in general thoracic surgery.

Objectives: Tumour infiltration, or gross infectious involvement of the thoracic aortic wall, poses a significant intraoperative risk for fatal bleeding and therefore could compromise adequate resection or efficient surgical management of pleural infection in a considerable amount of cases. We present 3 successful cases of off-label thoracic aortic endografting to safeguard thoracic aortic wall integrity.

Methods: After all patients received thoracic stent grafts through femoral access into the descending aorta, the first patient underwent a resection of a locally advanced squamous cell carcinoma of the left inferior lobe cT4cN0-1cM0 after neoadjuvant chemoradiation, which had infiltrated the descending aortic wall. The second case was video-assisted thoracoscopic bilateral pleural decortication for empyema with aortic ulcers of the distal thoracic aorta in a patient with pancreatic intrathoracic fistula in a necrotizing pancreatitis. The third patient was operated for a locally advanced squamous cell carcinoma of the left inferior lobe initial stage cT4 cN1-2 cM0 after neoadjuvant chemoradiation, which had broad contact to the descending aorta at the level of thoracic vertebrae 7 and 8 on a circumference of circa 180°. Regional ethics committee approval according the Swiss Federal Human Research Act was obtained according to regulations.

Results: Preventive stent graft placement resulted in complication-free resection and significantly minimized the risk of fatal intraoperative bleeding. Patients were thus not exposed to complications associated with aortic cross-clamping, possible prosthetic replacement and extracorporeal circulation techniques.

Conclusions: In carefully selected patient populations, the resection of locally advanced tumours or infectious processes involving the aortic wall can be facilitated by thoracic endovascular aortic repair prior to resection.