Ann Thorac Surg 1997;63:244-246
© 1997 The Society of Thoracic Surgeons
Case Report
Stent Angioplasty for Renovascular Disease Associated With Acute Aortic Dissection
Masaki Hata, MD,
Masayuki Zuguchi, MD,
Haruo Saito, MD,
Koichi Tabayashi, MD
Departments of Thoracic and Cardiovascular Surgery and Radiology, Tohoku University School of Medicine, Sendai, Japan
Accepted for publication July 22, 1996.
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Abstract
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Aortic replacement was performed in a patient with acute type A aortic dissection originating from the descending thoracic aorta. Postoperatively, a persistent false lumen resulted in severe stenosis of the right renal artery. Percutaneous stent angioplasty improved renovascular hypertension and renal function. This procedure is useful for management of patients with branch complications of arotic dissection.
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Introduction
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Renal artery complications associated with acute aortic dissection cause significant operative morbidity [1]. They also can affect the long-term outcome of surgical survivors, because stenotic lesions that persist or develop postoperatively can induce renovascular hypertension and renal failure.
Although percutaneous renal angioplasty has been extensively used for fibromuscular or atherosclerotic renovascular hypertension, few cases have been reported in patients with aortic dissection [2, 3]. The following case report describes stent angioplasty for severe stenosis of the right renal artery in a patient who underwent operation for an acute type A aortic dissection originating from the descending thoracic aorta.
In March 1995, a 57-year-old woman was diagnosed with an acute type A aortic dissection and underwent emergency partial replacement of the proximal aortic arch that had a false lumen. The intimal tear located in the descending thoracic aorta could not be resected through a median sternotomy.
Postoperatively hypertension developed that was difficult to control. Her systolic blood pressure frequently exceeded 180 mm Hg in spite of the intravenous administration of nicardipine. Her blood pressure was barely controlled (132/90 mm Hg on average) 1 month later with five antihypertensive drugs, including clonidine, prazosin, bisoprolol (ß-blockers), nifedipine, and imidapril (angiotensin-converting enzyme inhibitor). Her serum creatinine and blood urea nitrogen levels remained normal, but the right glomerular filtration rate was decreased on a renoscintigram, whereas the left one was normal. Her renin activity was elevated at 9.59 ng•mL-1•h-1 (normal, range, 0.5 to 2.0 ng•mL-1•h-1). Postoperative computed tomographic scan showed a persistent false aortic lumen through the descending thoracic aorta to the iliac artery. An intravenous digital subtraction angiogram demonstrated obstruction of the right renal artery, which was compressed by the false aortic channel (Fig 1A
). There was no other visceral or lower extremity ischemia.
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Fig 1. . (A) The right renal artery was almost completely occluded on an intravenous digital subtraction angiogram (arrow). (B) Selective angiography via the true aortic lumen clearly demonstrated the distal renal artery. (C) After angioplasty, an intravenous digital subtraction angiogram showed good filling of both renal arteries.
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In May 1995, percutaneous renal angioplasty was attempted to restore blood flow to the right kidney. Selective angiography via the true aortic lumen clearly demonstrated the distal right renal artery without intimal disruption (Fig 1B
). First, the lesion was dilated by conventional balloon angioplasty, but it immediately reoccluded. After we introduced a Palmaz vascular stent (Johnson & Johnson Co, Warren, NJ), the lesion was successfully dilated to a diameter of 4 mm, the same as that of the distal portion (Fig 1C). A routine intravenous digital subtraction angiogram 3 months after the angioplasty showed 50% restenosis, but the lesion was redilated easily by balloon angioplasty.
For up to 1 year after the first angioplasty, her renin activity has normalized and the hypertension has been controlled (140/89 mm Hg in average) with fewer antihypertensive drugs (three). Improvement of the right glomerular filtration rate (from 36% to 63% compared with the left one) was shown on the renoscintigram 1 month after the first procedure.
She has been followed up without further operation because computed tomographic scans performed every 6 months confirmed that the descending thoracic aortic diameter remained 45 mm.
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Comment
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In acute type A aortic dissection, the need for operation is well established. If the predominant aortic lesion (intimal tear) is located in the descending thoracic aorta, the choice of surgical approach, median sternotomy or lateral thoracotomy, remains controversial [4]. In our case, the ascending part had a false aortic lumen dilating moderately, so it was replaced through a median sternotomy to avoid a life-threatening event. Unfortunately, the postoperative status resembled a type B aortic dissection because of the persistent false lumen in the descending thoracic aorta.
Type B aortic dissection without visceral ischemia or dilated aorta can be treated medically. Our patient's case was complicated with severe stenosis of the right renal artery. However, percutaneous stent angioplasty made it possible to manage her case without further operation.
Modern pharmacotherapy, including angiotensin-converting enzyme inhibitors, allows adequate blood pressure control in most patients with renovascular disease, but progressive deterioration of renal function has been documented in these patients [5]. Uncontrolled hypertension and renal dysfunction are described as significant predictors of late death in patients who have survived operation for aortic dissection [6]. Therefore, renovascular disease associated with aortic dissection should be treated.
Although repair of the aortic region, renal artery bypass, or fenestration of the false aortic channel might be recommended, percutaneous renal stent angioplasty is another therapeutic option. It is far less invasive. If aneurysmal dilatation occurs in the future, we will do the surgical repair of the aortic region.
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Footnotes
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Address reprint requests to Dr Hata, Department of Thoracic and Cardiovascular Surgery, Tohoku University School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, 980-77, Japan (e-mail: mhata{at}mail.cc.tohoku.ac.jp).
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References
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- Fann JI, Sarris GE, Mitchell RS, et al. Treatment of patients with aortic dissection presenting with peripheral vascular complications. Ann Surg 1990;212:705–13.[Medline]
- Lacombe P, Mulot R, Labedan F, et al. Percutaneous recanalization of a renal artery in aortic dissection. Radiology 1992;185:829–31.[Abstract/Free Full Text]
- Walker PJ, Dake MD, Mitchell RS, Miller DC. The use of endovascular techniques for the treatment of complications of aortic dissection. J Vasc Surg 1993;18:1042–51.[Medline]
- Von Segesser LK, Killer I, Ziswiler M, et al. Dissection of the descending thoracic aorta extending into the ascending aorta: a therapeutic challenge. J Thorac Cardiovasc Surg 1994;108:755–61.[Abstract/Free Full Text]
- Dean RH, Kieffer RW, Smith BM, et al. Renovascular hypertension: anatomic and renal function changes during drug therapy. Arch Surg 1981;116:1408–15.[Abstract/Free Full Text]
- Haverich A, Miller DC, Scott WC, et al. Acute and chronic aortic dissections: determinants of long-term outcome for operative survivors. Circulation 1985;72(Suppl 2):22–34.
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Abstract
Introduction
