Hybrid imaging to facilitate accurate placement of a thoracic endovascular aneurysm repair before completion esophagectomy

A 58-year-old man presented with recurrent esophageal adenocarcinoma abutting the descending thoracic aorta. He had undergone partial esophagectomy 2 years previously, followed by chemotherapy and radiation. A recent esophagoscopy and biopsy indicated local recurrence. A second round of chemotherapy and concomitant esophageal stent placement was undertaken before presenting for resection of his mass and completion esophagectomy. Given the proximity of the tumor to the thoracic aorta, the previous radiation therapy, and the nature of a redo field in the chest, a thoracic endograft was placed under Dyna and fluoro computed tomography (CT) to facilitate the esophagectomy by preventing aortic interruption/rupture during the thoracic dissection (Cover). The images were acquired by the Siemens Artis Zeego Dyna-CT Rotational Angiography system at our Hybrid Operating Room and reconstructed at our syngo XWP (Siemens AG, Forchheim, Germany) clinical workstation. This Dyna-CT image after thoracic endovascular aneurysm repair placement demonstrates both the thoracic and esophageal stents in place. Dyna-CT with adequate postimaging 3D software can provide on-table information regarding aortic anatomy, including curvature, angulation, conicity, intramural thrombus, diameters, center-line lengths, landing zones, spinal/lumbar arteries and large collaterals; all with one modality. Upgrades in fixed C-arm imaging have facilitated wider fields of view. Furthermore, integrated Dyna-CT images can be overlaid to in vivo arteriography during thoracic endovascular aneurysm repair placement. The use of Dyna-CT allowed precise avoidance of the left subclavian artery and the distal accessory spinal artery supplying watershed areas of the spinal cord (Artery of Adamkiewicz). The patient safely tolerated his completion esophagectomy and resection of mediastinal mass without risk to his descending thoracic aorta. The use of Dyna-CT confirms prior esophageal and cardiac modeling to provide highly accurate and precise imaging over multislice CT alone.