Ann Thorac Surg 2002;73:1621-1623
© 2002 The Society of Thoracic Surgeons
Case report
Conventional repair and operative stent-grafting for acute and chronic aortic dissection
Takeshi Miyairi, MD*a,
Mikio Ninomiya, MDa,
Munemoto Endoh, MDa,
Junichi Naganuma, MDa,
Yutaka Kotsuka, MDa,
Shinichi Takamoto, MDa
a Department of Cardiothoracic Surgery, University of Tokyo, Tokyo, Japan
Accepted for publication August 31, 2001.
* Address reprint requests to Dr Miyairi, Department of Cardiothoracic Surgery, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, 113-8655 Tokyo, Japan
e-mail: tmiyairi-tky{at}umin.ac.jp
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Abstract
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Conventional graft replacement of the ascending aorta and surgically endovascular stent-grafting of the proximal descending aorta were performed concomitantly in a 82-year-old woman with an acute DeBakey type II aortic dissection and a chronic DeBakey type IIIb aortic dissection. Postoperative computed tomography and angiography showed the adequately replaced ascending-aortic prosthesis, the well-expanded stent-graft, and the thrombosed false lumen in the descending aorta.
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Introduction
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Endovascular stent-grafting is an innovative technique for treatment for aortic aneurysms [1], the application of which has been recently extended to aortic disection [2–6]. The objective of the method is to seal the entry site and promote thrombosis in the false lumen. We performed surgically endovascular stent-grafting of the proximal descending aorta for a chronic DeBakey type IIIb aortic dissection concomitantly in a patient who underwent conventional graft replacement of the ascending aorta for an acute DeBakey type II aortic dissection.
An 82-year-old woman, who had been followed for chronic DeBakey type IIIb aortic dissection for 6 years, was admitted to our hospital with acute chest and back pain. The day after admission, contrast-enhanced computed tomography revealed an acute DeBakey type II aortic dissection in addition to a chronic DeBakey type IIIb aortic dissection that did not show any changes in size and shape compared with the computed tomography taken 2 years previously, with the maximal diameter of 50 mm (Fig 1A).
Because no dissection was observed in the aortic arch, the acute aortic dissection was considered to be a new lesion independent of the chronic aortic one. Transesophageal echocardiography revealed an intimal tear of acute dissection in the ascending aorta 1 cm proximal to the origin of the right brachiocephalic artery, as well as one of chronic dissection in the descending aorta 2 cm distal to the origin of the left subclavian artery. Mild pericardial effusion was also noted. An emergency operation for acute aortic dissection with concomitant performance of endovascular stent-graft placement for chronic aortic dissection was prepared.
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Fig 1. (A) Contrast-enhanced computed tomography demonstrating aortic dissection both in the ascending and descending aorta without dissection in the aortic arch. (B) Contrast-enhanced computed tomography 10 days postoperatively demonstrating thrombosis in the false lumen of the descending aorta.
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The operation was performed via a median sternotomy. Cardiopulmonary bypass was established with the arterial flow in the ascending aorta and bicaval venous drainage. The body was cooled down and hypothermic circulatory arrest was instituted at the tympanic temperature of 18°C. Retrograde cerebral perfusion via the superior vena cava at a rate of 300–500 ml per minute was administered, and the myocardium was protected by intermittent antegrade infusion of cold blood cardioplegia. An incision was made on the ascending aorta, which was markedly enlarged and discolored with subadventitial hematomae. Acute aortic dissection extending from the sinotubular junction of the ascending aorta to just below the origin of the brachiocephalic artery was observed. Fresh thrombus in the proximal false lumen and an intimal tear at the site that was diagnosed preoperatively were noted. The aortic arch and cephalic vessels were free from dissection. The intimal tear of the chronic aortic dissection in the descending aorta was also confirmed through the aortic incision. A stent-graft made from a 30 x 75-mm self-expandable Gianturco Z-shaped stent (William Cook Europe, Bjaverskov, Denmark) and a 30-mm thin-walled woven Dacron graft was advanced into the descending aorta using a 24F sheath catheter through the aortic incision. Under the guidance of transesophageal echocardiography, the stent-graft was placed in the true lumen of the descending aorta beyond the intimal tear of the chronic dissection. Then, the ascending aorta was replaced with a 26-mm collagen-coated woven Dacron (C. R. Bard, Haverhill, PA) prosthesis, in the usual fashion (Fig 2).
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Fig 2. (A) Acute DeBakey type II dissection and chronic DeBakey type III dissection. The aortic arch is free from dissection (T = true lumen; F = false lumen [acute dissection]; F' = false lumen [chronic dissection]). (B) The stent-graft is delivered into the true lumen of the descending aorta using the sheath catheter. (C) The ascending aorta is replaced with a prosthetic graft in the usual fashion.
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The postoperative course was uneventful. Contrast-enhanced computed tomography on the 10th postoperative day demonstrated that the false lumen in the descending aorta had been thrombosed (Fig 1B). Aortography, performed on the 21st postoperative day, showed an adequately replaced ascending-aortic prosthesis and a well-expanded stent-graft with no leaks. The patient was discharged 26 days after the operation with no complications.
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Comment
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Chronic aortic dissection with the entry site in the descending aorta, whether or not dissection involves retrograde extension into the ascending aorta, has been the best subject for the endovascular stent-graft and favorable results have been reported [2–4]. However, catheter-based placement of endovascular stent-graft is difficult in patients with kinking abdominal aorta or extremely narrowed true lumen of the descending aorta. In addition, we occasionally encounter patients who require concomitant surgical intervention to the heart through median sternotomy, such as coronary artery bypass grafting. In those patients, delivery of the stent-graft through the aortic incision during open surgery might be a useful modality. Since 1996, we have used endovascular stent-graft during open surgery for distal aortic arch aneurysm or chronic aortic dissection with a significant decrease in operative mortality. As was reported previously, transesophageal echocardiography is a very useful tool for safe and accurate placement of the stent-graft [5].
Concerning acute aortic dissection involving the ascending aorta, the gold standard of treatment is—even today—conventional graft replacement. Recently, acute dissection with the entry in the descending aorta (retrograde extension) has become a target for catheter-based endovascular treatment [6]. Although this is a promising method, in cases with life-threatening complications such as impending rupture of the ascending aorta, severe aortic regurgitation, or obstruction of the coronary ostium, it might be inappropriate to expect endovascular stent-grafting to avert these complications. Moreover, in acute aortic dissection, advancement of the stent-graft has the potential hazard of injuring the fragile intima and adventitia. Therefore, we are of the opinion that the combined procedure presented herein—with graft replacement for the ascending aorta and intraoperative placement of the endovascular stent-graft to seal the entry site in the descending aorta—can be an option for treatment of acute aortic dissection originating in the descending aorta and extending into the ascending aorta.
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References
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Abstract
Introduction
