Ann Thorac Surg 1997;64:242-244
© 1997 The Society of Thoracic Surgeons
Case Report
Thoracoabdominal Fenestration for Aortic Dissection With Ischemic Colonic Perforation
Jimmy F. Howell, MD,
Scott A. LeMaire, MD,
Randall P. Kirby, MD
Department of Surgery, Baylor College of Medicine, The Methodist Hospital, Houston, Texas
Accepted for publication February 17, 1997.
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Abstract
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Previous attempts at repair of aortic dissection complicated by intestinal infarction requiring concomitant bowel resection have been fatal. Presented is a case of distal aortic dissection resulting in colonic infarction and perforation. Thoracoabdominal aortic fenestration with concomitant right hemicolectomy was successful. In patients with aortic dissection complicated by mesenteric ischemia, we recommend urgent graft replacement of the thoracoabdominal aorta when feasible. When peritoneal contamination precludes the use of prosthetic grafts, thoracoabdominal fenestration is an effective option.
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Introduction
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Early survival after graft replacement of the thoracoabdominal aorta in patients with either acute or chronic distal aortic dissection (DeBakey types I and III) currently exceeds 90%. Previous attempts at repair of thoracoabdominal dissection with coexisting bowel infarction, however, have been fatal [1–3]. Presented is a case of distal aortic dissection in which ischemic colonic perforation precluded prosthetic graft placement and required an unusual operative approach: fenestration of the thoracoabdominal aorta with concomitant colon resection.
A 40-year-old hypertensive man presented to an outside hospital with chest pain radiating to the back and epigastrium, with associated dyspnea, nausea, and diaphoresis. A computed tomographic scan revealed a distal aortic dissection and a thoracoabdominal aortic aneurysm (Crawford extent II) with a 5-cm diameter. Mild abdominal pain and guaiac-positive diarrhea developed. The patient's condition improved with medical treatment, and he was discharged on antihypertensive therapy 14 days after presentation. Three days later, he presented to the Methodist Hospital with worsening nausea, anorexia, and abdominal pain. Aortography (Fig 1
) revealed celiac axis occlusion with retrograde filling via collaterals from the superior mesenteric artery (SMA); the SMA and right renal artery arose from the markedly compressed true lumen.
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Fig 1. . (A) Preoperative aortogram and drawing demonstrating distal aortic dissection. The celiac axis is occluded and receives retrograde flow from the superior mesenteric artery. The true lumen, from which the superior mesenteric and right renal arteries arise, is severely compressed by the false lumen. (B) Postoperative aortogram and drawing demonstrating restoration of flow in the visceral vessels. Patency of the superior mesenteric artery-which overlies the opacified aorta and is therefore obscured in this view-is demonstrated by visualization of its branches.
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Exploration through a left thoracoabdominal incision revealed a gangrenous gallbladder and right colon infarction with perforation and peritoneal contamination. After the distal descending thoracic aorta was clamped, the thoracoabdominal aorta was opened along its posterolateral aspect. The exposed septum was excised, leaving buttons of tissue around each of the visceral vessels (Fig 2A). Pledgeted 4-0 polypropylene was used to obliterate the distal false lumen and reattach the visceral vessels to the outer aortic wall (Fig 2B). The aortotomy was closed with continuous 4-0 polypropylene (Fig 2C). A closed suction drain was placed near the aortic repair. A cholecystectomy and right hemicolectomy with side-to-side ileocolic anastomosis were performed.
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Fig 2. . Operative repair included (A) thoracoabdominal aortotomy with excision of the intimal flap, (B) reattachment of the visceral vessels, obliteration of the distal false lumen, and (C) primary closure of the aortotomy.
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The patient's recovery was uneventful. Intravenous administration of antibiotics was continued until his fever resolved. He was discharged on a regimen of minocycline and metoprolol. Postoperative aortography confirmed patency of the visceral and iliac arteries (Fig 1B
). The patient remained well at follow-up 1 year later.
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Comment
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Intestinal ischemia after aortic dissection usually results from compression of the SMA origin by the false lumen hematoma or from extension of the dissection into the SMA ostea; either situation can cause SMA thrombosis. This case is unusual in that celiac axis occlusion resulted in gangrene of the gallbladder and steal of flow from the SMA, which was already compromised by the narrowed true lumen, causing secondary colonic infarction. Cogbill and associates [4] reported a similar situation in a patient who had chronic distal dissection and intestinal angina without visceral infarction.
Mortality rates for aortic dissection with symptomatic bowel ischemia range from 60% to 100% [1, 3, 5]. Of 264 patients with distal aortic dissections reported by Cambria and associates [1], only 8 (3%) had mesenteric infarction. All 8 patients died despite bowel resection, revascularization, or both; seven deaths were directly related to mesenteric infarction and one was due to ascending aortic rupture within a week of bowel resection. Fann and associates [3] reported deaths in 3 patients with acute aortic dissection who required small bowel resection for severe ischemia. One patient with an acute dissection reported by Cavaliere and associates [6] survived a left hemicolectomy performed 4 days after graft replacement of the ascending aorta. Here we report survival after repair of thoracoabdominal aortic dissection and concomitant bowel resection.
Techniques described for treating distal aortic dissection with branch vessel occlusion include graft replacement of the descending thoracic aorta to redirect flow into the true lumen, decompress the false lumen, and restore visceral perfusion [7]. Successful mesenteric revascularization using bypass grafts from the right iliac artery, which is usually spared in the dissection process, has been reported [5]. Cogbill and associates [4] revascularized the common hepatic artery using a 6-mm bypass graft from an infrarenal aortic graft. We and others [7] consider graft replacement of the involved thoracoabdominal aorta to be the ideal approach; however, the danger of graft infection in the presence of colonic perforation precluded its use in the present case.
Fenestration procedures involving partial resection of the intimal flap decompress the false lumen proximally and restore true lumen flow. The first fenestration procedure was described by Gurin and associates [8], who performed iliac artery fenestration in a patient with acute dissection and right leg ischemia. Elefteriades and associates [2] have reported 75% in-hospital survival in 12 patients with acute dissection who underwent infrarenal aortic fenestration. In their series, an 88-year-old patient with intestinal ischemia requiring concomitant bowel resection subsequently died of multisystem organ failure. Laas and associates [7] performed fenestration procedures in 7 patients with acute dissection with 43% survival. The abdominal aortic intimal flap was approached via the distal descending thoracic aorta in 1 patient, from directly above a previously placed infrarenal graft in 1 patient, and via the femoral artery-using a ring-stripper-in 4 patients. The final patient in Laas and associates' series had extension of the intimal flap into the SMA causing its occlusion; this was remedied by superior mesenteric arteriotomy with intimal fenestration and patch angioplasty. In our patient we performed direct thoracoabdominal aortotomy with fenestration of the segment from which the visceral vessels arose.
In conclusion, we recommend graft replacement of the thoracoabdominal aorta whenever feasible in patients with acute or chronic aortic dissection causing visceral ischemia. When peritoneal contamination precludes the use of prosthetic grafts, thoracoabdominal fenestration is an effective option.
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Footnotes
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Address reprint requests to Dr Howell, 6535 Fannin, MS A802, Houston, TX 77030.
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References
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- Cambria RP, Brewster DC, Gertler J, et al. Vascular complications associated with spontaneous aortic dissection. J Vasc Surg 1988;7:199–209.[Medline]
- Elefteriades JA, Hammond GL, Gusberg RJ, Kopf GS, Baldwin JC. Fenestration revisited: a safe and effective procedure for descending aortic dissection. Arch Surg 1990;125:786–90.[Abstract/Free Full Text]
- 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]
- Cogbill TH, Gundersen AE, Travelli R. Mesenteric vascular insufficiency and claudication following acute dissecting thoracic aortic aneurysm. J Vasc Surg 1985;2:472–6.[Medline]
- Odagiri S, Koide S, Ariizumi K, et al. Successful right common iliac to superior mesenteric artery bypass for mesenteric ischemia associated with acute aortic dissection: report of a case. Surg Today 1993;23:1014–7.[Medline]
- Cavaliere F, Martinelli L, Guarneri S, Morelli M, Possati GF, Schiavello R. Creatine-kinase isoenzyme pattern in colonic infarction consequent to acute aortic dissection: a case report. J Cardiovasc Surg 1993;34:263–5.[Medline]
- Laas J, Heinemann M, Schaefers HJ, Daniel W, Borst HG. Management of thoracoabdominal malperfusion in aortic dissection. Circulation 1991;84(Suppl 3):20–4.
- Gurin D, Bulmer JW, Derby R. Dissecting aneurysm of aorta: diagnosis and operative relief of acute arterial obstruction due to this cause. N Y State J Med 1935;35:1200–2.
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Abstract
Introduction
