Ann Thorac Surg 2002;73:1616-1618
© 2002 The Society of Thoracic Surgeons
Case report
Type-A acute aortic dissection: combined operation plus stent management
Daniel Roux, MD*a,
Laurent Brouchet, MDa,
Philippe Concina, MDa,
Tamer Elghobary, MDa,
Yves Glock, MD, PhDa,
Gérard Fournial, MDa
a Department of Cardiovascular Surgery, Hôpital de Rangueil, Toulouse, France
Accepted for publication October 10, 2001.
* Address reprint requests to Dr Roux, Département de Chirurgie Cardiovasculaire, Hôpital de Rangueil, 1 Ave Jean Poulhes, 31403 Toulouse Cedex 4, France
e-mail: fournial.g{at}chu-toulouse.fr
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Abstract
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When the port of entry of acute type-A aortic dissection is at the level of the horizontal portion of the aortic arch, the latter should be replaced by a prosthesis. To avoid performing this difficult procedure in an emergency situation, we place a stent in the aortic arch. Then we replace the ascending aorta by a prosthesis.
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Introduction
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The risk of acute rupture of the ascending aorta in the pericardium justifies urgent intervention for the acute type-A aortic dissection [1]. The classic technique consists of replacing the ascending aorta by using a prosthesis. When the port of entry of the dissection is at the level of the transverse portion of the aortic arch, the classic technique consists of total replacement of the arch by a prosthesis. The procedure then becomes more difficult and the prognosis less favorable [2]. Therefore we performed a procedure that combines the perioperative stenting of the aortic arch and replacement of the ascending aorta by a prosthesis.
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Case reports
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Patient 1
A 58-year-old man presented with chest pain and shock. The electrocardiogram was normal. The diagnosis of acute type-A aortic dissection was made from a computed tomographic chest scan. The port of entry was located at the base of the left subclavian artery. The dissection extended distally to the isthmus and proximally into the ascending aorta. The descending thoracic aorta and the abdominal aorta were not affected.
The following procedures were performed as an emergency. The right femoral artery was cannulated (as the arterial line) and the right atrium was also by using a double pore cannula (as the venous line). Cardiopulmonary bypass and profound hypothermia (18°C) were established. During the period of cooling (26 minutes), we positioned the radioscopy apparatus in front of the aortic arch and prepared the device (Fig 1).
The device consists of a stent (Saint Come-Chirurgie; Marseille, France) mounted on a compliant balloon. The stent is made of a Steel 316 L, it is 14 cm long, consisting of three elements each of 4 cm long, and separated from each other by joints of 1 cm each. The stent can be adapted to the shape of the aortic arch [3]. This device has a diameter of 9 mm. A pressure of 220 mm Hg is necessary to open the stent; this pressure can be diminished as the stent opens. When the diameter of the stent reaches approximately 15 mm, a pressure of 160 mm Hg is sufficient to continue its opening.
When the patient’s core temperature reached 18°C, total circulatory arrest was performed. The ascending aorta was resected and the port of entry of the dissection was located. The device was positioned in the arch, and the balloon was inflated with a syringe containing a mix (50/50) of physiologic saline and a contrast. The balloon was inflated under the control of the radioscopy. During this period the assistant was injecting biological glue in the false lumen. We used the port of entry also to inject biological glue further in the false lumen. When the stent was well impacted in the aortic wall and the internal and external cylinders were well coapted, the balloon was deflated. A prosthesis was then sutured to the aorta and its proximal part was clamped.
This prosthesis has a side branch tube that permits a rapid connection with the arterial line of the cardiopulmonary bypass so that the extracorporeal circulation can be continued again in an anterograde manner. The period of total circulatory arrest was 14 minutes. During rewarming, the proximal part of the prosthesis was sutured to the aorta in the supracoronary position (Fig 2). When the core temperature reached 37°C and the hemodynamics were stable, the cardiopulmonary bypass was disconnected.
An immediate postoperative control transesophageal echocardiography was done, which showed the stent in a good position and well opened; it also showed the presence of a thrombosed residual false lumen measuring 4 mm in thickness (Fig 3).
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Fig 3. Patient 1: Immediate postoperative control by transesophageal echocardiography. (A = stent; B = residual thrombotic false lumen.)
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Four months after the operation, a follow-up computed tomographic chest scan was done, which confirmed the good surgical results. The aortic arch was not dilated, there was no circulation in the false lumen, and the stent was in a good position (Fig 4).
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Fig 4. Patient 1: Postoperative control by computed tomographic chest scan 4 months after intervention.
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Patient 2
A 77-year-old woman presented with characteristic chest pain. The diagnosis was confirmed through transesophageal echocardiography. The port of entry was situated between the left common carotid artery and the left subclavian artery. The dissection extended distally to the isthmus and proximally into the ascending aorta. The descending thoracic aorta and the abdominal aorta were not affected. We performed the same procedure as in the first patient. Total circulatory arrest was 38 minutes. The postoperative control echocardiography and computed tomographic chest scan revealed similar results as those of the first patient.
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Comment
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Emergency replacement of the aortic arch in acute type A aortic dissection is a high-risk procedure that increases the operative mortality and the postoperative morbidity when compared with simple replacement of the ascending aorta by a prosthesis [4]. This is why we established a combined technique, the positioning of a stent while injecting biological glue in the false lumen permits a good coaptation between the internal and the external cylinders. The 4-mm space, which was mentioned in the postoperative control echocardiography, is filled with the biological glue.
The time of total circulatory arrest is very short (14 minutes) in the first patient, because the stent together with the glue reinforces the aortic wall of the aorta and facilitates the sutures by keeping the lumen always opened. In the second patient, total circulatory arrest was longer because the sutures were done by a junior surgeon.
The stent renders the sutures more solidly between the Dacron prosthesis (Saint Come Chirurgie, Marseille, France) and the aorta, which avoids the occurrence of false aneurysm in the site of the anastomosis that sometimes occurs after conventional operations [5].
To avoid retrograde flow in the false lumen through the reentry pathways, which may exist in the abdominal or descending thoracic aorta, we shifted immediately to anterograde flow after total circulatory arrest instead of continued use of the retrograde flow of the femoral artery cannula.
The computed tomographic chest scan 4 months after the operation confirmed the good results. The stent was perfectly applied against the aortic wall, there was no false lumen, and the arch was not dilated.
In these 2 patients, the type A aortic dissection was limited to the aortic arch. This is why the technique has had good results. However, if there are other port of entries in the descending thoracic or abdominal aorta, applying our technique would not be sufficient to obtain good results. That is why we are aiming to apply this technique to the rest of the aorta later on.
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References
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Ehrlich M., Fang W.C., Grabenwöger M., Cartes-Zumelzu F., Wolner E., Havel M. Perioperative risk factors for mortality in patients with acute type A aortic dissection. Circulation 1998;98(Suppl II):II294-II298.
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Ando M., Nakajima N., Adachi S., Nakaya M., Kawashima Y. Simultaneous graft replacement of the ascending aorta and total aortic arch for type A aortic dissection. Ann Thorac Surg 1994;57:669-676.[Abstract]
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Michael S.T., Victor P., Richard S., Bruce J.B., et al. A balloon expandable intravascular stent for obliterating experimental aortic dissection. J Vasc Surg 1990;11:707-717.[Medline]
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Wong C., Bonser R.S. Does retrograde cerebral perfusion affect risk factors for stroke and mortality after hypothermic circulatory arrest?. Ann Thorac Surg 1999;67:1900-1903.[Abstract/Free Full Text]
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Bachet J.E., Termignon J.L., Dreyfus G., et al. Aortic dissection. Prevalence, cause and results of late reoperations. J Thorac Cardiovasc Surg 1994;108:199-206.[Abstract/Free Full Text]
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Abstract
Introduction
