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Ann Thorac Surg 2002;73:950-951
© 2002 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, Cardiologic Hospital, Lille, France
b Department of Vascular Radiology, Cardiologic Hospital, Lille, France
Accepted for publication January 2, 2002.
* Address reprint requests to Dr Fabre, Department of Cardiac Surgery, Cardiologic Hospital, Bd du Pr J. Leclercq, 59037 Lille Cedex, France
e-mail: o-fabre{at}chru-lille.fr
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Abstract |
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Introduction |
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A 71-year-old hypertensive man was admitted to the emergency department with pain radiating from the thorax to the abdomen. There was associated diarrhea and rectal hemorrhage but no vascular collapse. A thoracoabdominal computed tomography scan revealed acute type A aortic dissection involving the supraaortic trunks, celiac trunk, and superior mesenteric artery.
Clinical examination noted abdominal distension with guarding and absence of bowel sounds. Plain abdominal roentgenograms without bowel preparation showed bowel distension with some hydroaeric levels and diffuse gray areas.
Laboratory data revealed serum glutamic oxaloacetic transaminase (SGOT) = 877 IU/L (normal range: 5–37 IU/L), serum glutamate pyruvate transaminase (SGPT) = 851 IU/L (normal range: 5–41 IU/L), creatine phosphokinase (CPK) = 358 IU/L (normal range: 5–195 IU/l), and lactate concentration = 4.74 mmol/L (normal range: 0.65–2.45 mmol/L).
Surgical correction of the thoracic ascending aorta was delayed because of the severity of the abdominal symptoms and the prohibitive perioperative mortality. Percutaneous fenestration was thus performed to initially manage the mesenteric malperfusion. This procedure was performed 2 hours after the time of presentation and 5 hours after the symptoms commenced. In this procedure two rigid guidewires—one in the false lumen and one in the true lumen—were inserted through a single introducer sheath [1]. This system formed a pair of intravascular scissors that was advanced over several centimeters to cut the dissection flap and then restore adequate blood flow (Fig 1).
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Ascending thoracic aortic replacement with selective anterograde cerebral perfusion in moderate hypothermia (28°C) was performed 6 days later. The immediate postoperative course was uneventful with complete regression of abdominal pain and laboratory data normalization within 24 hours and 3 days, respectively. Intensive care unit stay was 10 days. The patient re-presented a few days later with recurrent right hypochondrial pain, nausea, and vomiting, with these symptoms occurring at the time a solid food diet was resumed. Colonoscopy and barium enema revealed an irregular right transverse colon stenosis probably secondary to extensive preoperative ischemia (Fig 2).
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The first problem concerns the choice of the technique of fenestration. Surgical aortic fenestration has been commonly used to create a re-entry tear in the false lumen. This procedure requires a thoracoabdominal incision, aortic transection, and section of the intimal flap. The results were satisfying in terms of reperfusion but the procedure was associated with a substantial mortality rate (43%) [3].
With the development of endovascular techniques, percutaneous fenestration has been proposed as an alternative to surgical procedures. The technique commonly used consists of the creation and enlargement of a re-entry tear with a balloon catheter [4]. Recurrence of malperfusion has been described with this technique because of the smaller size of the re-entry created by the balloon as compared with that achieved surgically. Our technique of endovascular scissors permitted the re-entry tear to mimic that achieved surgically without the drawback of the operation itself.
A second problem is the timing of the fenestration in the management of a patient with acute aortic dissection and malperfusion syndrome. Immediate aortic operation on patients with mesenteric complications protects them from aortic rupture, but results in increased ischemia if the aortic replacement does not restore adequate blood flow in the visceral arteries. Besides, cardiopulmonary bypass is associated with a diminution of splanchnic blood flow and therefore enhances the ischemic problem.
In our case, preoperative fenestration allowed the rapid correction of mesenteric malperfusion syndrome without general anesthesia. Aortic operation may then be performed under better hemodynamic conditions without risk of mesenteric injury. Deeb and colleagues [5] reported a significant decrease in mortality rate (15% versus 89%) when percutaneous fenestration was performed before aortic surgery.
In summary, preoperative percutaneous fenestration appears to be a good alternative in the case of severe visceral ischemia resulting from aortic dissection, in patients who are hemodynamically stable. The indication and usefulness of this form of fenestration should be discussed with the interventional radiologist, with the final decision depending on the hemodynamic and computed tomography scan parameters present.
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This article has been cited by other articles:
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  B. A. Sharpe and M. Klompas Clinical Manifestations of Acute Aortic Dissection JAMA, August 21, 2002; 288(7): 828 - 828. [Full Text] [PDF]
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