Ann Thorac Surg 1999;68:1067-1068
© 1999 The Society of Thoracic Surgeons
Case Reports
Repair of acute descending aortic dissection complicated by visceral ischemia
Nan Wang, MDa,
David T. Wong, MDa,
Jorge L. Rivera, MDa,
Ramesh C. Bansal, MDa,
Steven R. Gundry, MDa
a Division of Cardiothoracic Surgery, Department of Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
Address reprint requests to Dr Wang, Division of Cardiothoracic Surgery, Department of Surgery, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354
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Abstract
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Visceral ischemia is a rare but lethal complication of type III aortic dissection. We report a Marfan patient with such a complication who had a complete resolution of profound visceral ischemia despite a delay in repair of over 48 hours.
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Introduction
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The optimal operative approach to visceral ischemia from acute aortic dissection is still being disputed. Several operative alternatives have been proposed, including local resection of ischemic viscera alone, revascularization by distal aortic fenestration procedure, graft replacement of the proximal aorta, and graft replacement of the entire dissected aorta [1–3]. Reported operative mortality, in the setting of profound visceral ischemia from acute type III aortic dissection, is disappointing (80%–90%) [1, 2]. Our success in the treatment of such a patient with Marfan’s syndrome is reported.
A 32-year-old hypertensive woman with Marfan’s syndrome presented with severe abdominal pain and back pain. The pain was present for over 1 week but was acutely associated with vomiting and bloody diarrhea. Past medical history was significant for amphetamine abuse. Physical examination revealed right-sided tenderness and guaiao-positive stools.
She underwent an exploratory laparotomy. A segment of gangrenous small bowel was found associated with absence of Doppler signals in the superior mesenteric artery. The bowel was resected and primary anastomosis was performed. An aortogram (Fig 1) was then obtained that demonstrated dissection of the descending thoracic aorta with no flow to the mesenteric and left renal artery. The patient was referred to our center for further treatment.
Upon arrival, the patient continued to have severe abdominal pain. Her left lower extremity pulses were absent. Transesophageal echocardiogram was performed to further clarify the aortic anatomy. The origin of the tear on the aortic intima was discovered to be approximately 2–3 cm below the subclavian artery. No distal reentry could be visualized. The ascending aorta and arch were normal. A second-look laparotomy showed profound global visceral ischemia. The hepato-biliary system and the entire upper intestinal tract were dusky, with suspected areas of patchy necrosis in the gallbladder and small bowel. Again, no Doppler signals were detected in the celiac, superior mesenteric, and left iliac arteries.
Repair of the aortic dissection was then performed via left thoracotomy with femoral-femoral partial bypass. After proximal control of the aorta just below the subclavian artery, the segment of aorta with the intimal tear was resected. The false lumen in the distal aorta was obliterated using strips of felt, and a Hemashield Dacron graft (Meadox Medicals, Inc, Oakland, NJ) was sutured to the proximal and the newly constructed distal aorta. Blood flow to the true lumen was thus reestablished. A subsequent third laparotomy revealed complete resolution of all ischemic changes. The patient had an uneventful recovery.
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Comment
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We describe a rare case of global visceral ischemia from an acute DeBakey type III dissection that was treated successfully despite greater than 48 hours of profound ischemia. In general, most of the type III acute aortic dissection may be treated by aggressive medical manage
ment alone. However, immediate operative intervention is indicated when a dissection is complicated by end-organ ischemia [1, 2].
The literature revealed no consistent approach to the management of acute type III aortic dissection with visceral ischemia. This may be attributed to the scarcity of such an event. In a review of 505 autopsy cases, only 10% of all aortic dissections were found to involve the mesenteric arteries [4]. Clinically, it is even rarer for a patient to present with symptomatic mesenteric ischemia. Fann and associates from Stanford described 14 patients (5%) with visceral artery involvement as demonstrated by angiography in 272 patients with all types of aortic dissection [1]. Operative mortality was 43%. However, the mortality increased to 80% when the patient had clinical evidence of visceral ischemia requiring laparotomy. In another series from Yale and Massachusetts General Hospital, 7 of 8 patients who presented with frank bowel ischemia or infarction from type III dissection died [2]. Their approach to management consisted of exploration alone in 1 patient, bowel resection alone in 4 patients, bowel resection and revascularization by bypass grafts in 2 patients, and distal aortic fenestration in 1 patient.
Ischemic complications of aortic dissection is caused by obliteration of aortic true lumen and accompanied branches by a high-pressured bulging false lumen [5]. In our opinion, the most reliable method in reversing such a pathological change is by reestablishing flow into the true lumen. This is best accomplished by a short graft replacement of the aorta at the origin of the tear with circumferential obliteration of the distal false lumen (Fig 2). Distal aortic fenestration has been proposed by Elefteriades and associates [6], as another option to reperfuse the true lumen. However, adequate flow in the true lumen may not be reliably established by this method. There may be a risk of subsequent thrombosis of either the true or false lumen. In the setting of acute dissection, particularly in a Marfan patient, aortotomy in the distally dissected aorta is extremely hazardous.
Because irreversible ischemia is a time-dependent event, expedient diagnosis and treatment are necessary. As clearly demonstrated by our approach, repair of the aorta by obliterating the false lumen and redirecting flow into the true lumen can lead to complete visceral revascularization. This case also suggest that even after more than 48 hours, profound ischemia may be reversible. Revascularization should therefore precede any consideration of bowel or other visceral resection. The rapid evaluation of the aorta by transesophageal echocardiogram [7] and the prompt repair of the aortic dissection led to a satisfactory outcome in this patient.
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References
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Elefteriades J.A., Hammond G.L., Gusber R.J., Kopf G., Baldwin J.C. Fenestration revisited. Arch Surg 1990;125:786-790.[Abstract/Free Full Text]
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Bansal R.C., Chandrasekaran K., Ayala K., Smith D.C. Frequency and explanation of false negative diagnosis of aortic dissection by aortography and transesophageal echocardiography. J Am Coll Cardiol 1995;25:1393-1401.[Abstract]
Accepted for publication January 20, 1999.
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Abstract
Introduction
