Ann Thorac Surg 2002;73:288-291
© 2002 The Society of Thoracic Surgeons
Case report
Endovascular stent grafting of the descending thoracic aorta after arch repair in acute type A dissection
Hiromi Yano, MD*a,
Shin Ishimaru, MDa,
Satoshi Kawaguchi, MDa,
Yukio Obitsu, MDa
a Department of Surgery II, Tokyo Medical University, Tokyo, Japan
Accepted for publication March 14, 2001.
* Address reprint requests to Dr Yano, Department of Surgery II, Tokyo Medical University, 6-7-1 Nishi-shinjyuku, Shinjyuku-ku, Tokyo 170-0023, Japan
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Abstract
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An endovascular stent graft was successfully deployed to the primary entry site in the proximal descending thoracic aorta after total aortic arch replacement using the "elephant trunk" technique in acute type A aortic dissection. The residual false lumen of the descending aorta was thrombosed completely after stent grafting. The elephant trunk was feasible for a proximal landing zone for stent grafting of the descending aorta. Stent grafting in combination with aortic arch replacement was a safe and effective procedure, and may be an alternative choice in carefully selected patients with type A aortic dissection.
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Introduction
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Total aortic arch replacement has been applied to acute type A aortic dissection, but this procedure has problems with a residual false lumen and multiple residual entries. We performed total aortic arch replacement using the "elephant trunk" as the first operation in acute type A aortic dissection to prevent cardiac tamponade or rupture. A residual entry site was located below the distal anastomosis. Four weeks later, endovascular stent grafting was performed for the entry site as a second operation; a successful outcome was obtained.
A 47-year-old man was referred to our hospital with severe back pain. A computed tomogram demonstrated a type A aortic dissection (Fig 1).
An endoesophageal echocardiogram showed cardiac tamponade and an intimal tear distal to the origin of the left subclavian artery.
We performed an emergency operation using hypothermic circulatory arrest with selective cerebral perfusion. The intimal tear was located in the descending aorta below the subclavian artery. We performed graft replacement of the ascending aorta and total aortic arch with a woven double-velour Dacron graft (Hemashield; Meadox Medicals, Oakland, NJ) using the elephant trunk technique to easily insert the endovascular stent graft as a second operation for entry closure. A 24-mm Dacron graft was used for replacement and a 22-mm Dacron graft was inserted into the descending aorta; the length of the elephant trunk was 4 cm. Dissected aortic layers in the aortic arch proximal to the subclavian artery were refixed with gelatin-resorcin-formaldehyde-glutaraldehyde (GRF) tissue adhesive (Colle Biologique Gelatine Resorcine Formol; Cardial, Saint-Etienne, France). A computed tomogram (Fig 2A)
and a digital subtraction angiogram (Fig 2B) taken 2 weeks later demonstrated blood flow into the false lumen and compressed true lumen in the descending aorta.
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Fig 2. Computed tomogram (A) and digital subtraction angiogram (B) demonstrating blood flow into the false lumen 2 weeks after the first operative procedure.
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Endovascular stent grafting was performed 4 weeks later. The stent graft was composed of three units of self-expanding Z stents covered with thin-wall polyester fabric (Fig 3).
Under general anesthesia, a femoral artery was isolated and incised after systemic heparinization (50 U/kg IV). A 10F intravascular ultrasound (IVUS) imaging catheter (10 MHz; CVIS, Meditech, Boston, MA) was introduced over a 0.025-in. guidewire through the sheath to observe the morphology of the aorta. After observation, a 5F sheath was inserted by direct puncture into the right brachial artery followed by a 400-cm guidewire pulled through from the right brachial artery to the femoral artery. An 18F J-type delivery sheath was passed over this wire through an open femoral arteriotomy and placed in the elephant trunk ("tug of wire method" [1]). A stent graft (26 mm diameter, 75 mm length) was inserted into the sheath using a pushing rod. The stent graft was placed from the proximal end of the elephant trunk to the descending aorta. A digital subtraction angiogram showed closure of the entry site, but much blood flow into the false lumen and compression of the true lumen still remained. The IVUS catheter was introduced again and demonstrated fluttering of the intimal flap which compressed the true lumen from the distal end of the stent graft to 4 cm distal to the stent graft. This may be due to injury of the intimal flap by the edge of the stent. We performed additional stent grafting to close an intimal flap injury and to reinforce the true lumen using a 22-mm to 75-mm woven Dacron graft. Completion angiography showed a remarkable decrease in blood flow into the false lumen and improvement of the narrow true lumen. The IVUS demonstrated smoky echoes in the false lumen, which might indicate a decrease in blood flow (Fig 4).
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Fig 3. The custom-made stent graft is composed of self-expanding Z stents covered with thin-wall polyester fabric.
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Fig 4. Intravascular ultrasound demonstrating smoky echoes around the stent graft which might indicate a decrease in blood flow or thrombus in the false lumen.
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A computed tomogram (Fig 5A)
and a digital subtraction angiogram (Fig 5B) after 2 weeks showed thrombosis of the false lumen in the descending aorta. The patient had no neurologic complications and was well when discharged home.
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Fig 5. Computed tomogram (A) and digital subtraction angiogram (B) at 2 weeks after stent grafting showing the thrombosis of the false lumen in the descending aorta and closure of the entry site.
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Comment
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Since Borst and colleagues [2] described the usefulness of the "elephant trunk" technique as a multiple-stage operation in 1983, it has been applied to extensive aortic aneurysms. Modified procedures [3, 4] have been reported and these techniques also have been used in aortic dissection. Successful obliteration of the false lumen has been reported [3]. As this technique is the process for the next stage operation originally, progression of the false lumen due to blood flow from reentry or from residual entry might occur. It is reported that the descending aorta seems to be the area most prone to expand [5].
In this case we intended to transect the aorta between the carotid artery and subclavian artery to get good vision for suturing the distal anastomosis and planned to close the entry site by using a stent graft later. For the acute phase graft replacement of the ascending aorta and arch using an "elephant trunk" was performed; this produced a type 3B dissection.
After the acute phase an endovascular stent graft was deployed at the entry site in the descending aorta to close the site and to inhibit progression of the false lumen. Kato and associates [6] described the new graft implanting method using a stented graft, which is inserted into the descending aorta through an incision in the aorta. But this method has a few problems. First, from a median sternotomy the surgical field is deep within the body so that it is difficult to insert a stent graft into the ideal site without tearing the fragile intima. Second, an end leak cannot be detected during the procedure. For these reasons it is better to deploy a stent graft as a second operation after the acute phase using fluoroscopic and IVUS guidance. Even though an intimal tear occurred at the distal landing zone and further stent grafting was needed to cover it, successful deployment was attained and was followed by thrombosis of the false lumen. Technically placement of a stent graft into a prosthetic graft was easier compared with placement in the aortic dissection.
The advantages of an endovascular stent graft include reduction in procedural time, blood loss, and length of intensive care and hospital stay [7]. In addition, it may be associated with lower rates of morbidity and mortality. There also is a case report of endovascular stent grafting after arch aneurysm repair using the "elephant trunk" in a patient with extensive aneurysmal disease [8]. The elephant trunk technique followed by an endovascular stent graft in the descending aorta could be an alternative therapeutic procedure in patients with type A aortic dissection. This procedure will, however, require careful long-term evaluation.
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References
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Ishimaru S., Kawaguchi S., Koizumi N., et al. Preliminary report on prediction of spinal cord ischemia in endovascular stent graft repair of thoracic aortic aneurysm by retrievable stent graft. J Thorac Cardiovasc Surg 1998;115:811-818.[Abstract/Free Full Text]
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Borst H.G., Walterbusch G., Schaps D. Extensive aortic replacement using elephant trunk prosthesis. J Thorac Cardiovasc Surg 1983;31:37-40.
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Heinemann M., Laas J., Karck M., et al. Thoracic aortic aneurysms after acute type A aortic dissection: necessity for follow-up. Ann Thorac Surg 1990;49:580-584.[Abstract]
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Kato M., Ohnishi K., Kaneko M., et al. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation 1996;94(Suppl 2):188-193.
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Abstract
Introduction
