Ann Thorac Surg 2002;74:2186-2189
© 2002 The Society of Thoracic Surgeons
Case report
Open surgical intervention to recurrent aortic dissection after endovascular stent grafting
Masato Machii, MDa*,
Kuniyoshi Ohara, MDa,
Hiroshi Imai, MDa,
Zong Bo Lin, MDa,
Kyouichi Sudo, MDa,
Hirokuni Yoshimura, MDa
a Department of Thoracic and Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
Accepted for publication July 10, 2002.
* Address reprint requests to Dr Machii, Department of Thoracic and Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Sagamihara, Kanagawa 228-8555, Japan.
e-mail: machii{at}med.kitasato-u.ac.jp
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Abstract
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We report the case of a 49-year-old man who received open-heart surgery for recurrent aortic dissection after endovascular stent grafting. Stent grafting had been successfully performed in the acute phase. Recurrent dissection became obvious 5 months later, and at the same time, aneurysmal change was detected between the left subclavian artery and the proximal end of the stent graft. We employed a "Y arch" surgical procedure and "elephant trunk" technique to treat, and the entry tear was completely sealed and the aneurysm was excluded by elephant trunk segment. We believe that this approach could be a new option for treatment for complicated aortic aneurysms.
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Introduction
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Endovascular stent grafting has been emerging as a less-invasive alternative to conventional surgical grafting in selected patients. But once it fails, aggressive endoluminal intervention or surgical operation is inevitable. Here, we present a case receiving open surgery for recurrent aortic dissection after endovascular stent grafting.
A 49-year-old man with untreated hypertension had serious back pain and was transferred to Kitasato University Hospital on an emergency basis. The patient was diagnosed with type B acute aortic dissection by chest computed tomography (CT). Soon after diagnosis, his blood pressure was controlled with continuous intravenous infusion of nicardipine hydrochloride. His blood pressure was maintained around 100 mm Hg without any symptoms. The patient was admitted to the intensive care unit, and received antihypertensive therapy. On day 2, we performed aortography, which revealed a primary tear existing 4 cm distal from the left subclavian artery (Fig 1A).
With fully informed consent, the patient chose endovascular stent grafting as the therapeutical method rather than medical control of his blood pressure. On day 3, a tailor-made stent graft was implanted endoluminally. He recovered uneventfully, and postoperative aortography did not reveal any endoleakage (Fig 1B), except for a locally patent false lumen just below the diaphragm. Five months after endovascular stent garfting, follow-up aortography was performed, because previous chest CT examination showed opacification of the false lumen, which had once been obliterated by the stent graft. As expected, the aortography showed opacification of the false lumen through the tear at the proximal end of the stent graft, which seemed to be injured by the stent graft itself. Moreover, a small protrusion of the aortic wall between the origin of the left subclavian artery and proximal end of the stent graft was detected (Fig 1C). Therefore, we decided to operate 7 months after the endovascular stent grafting. We chose median sternotomy to approach the aortic arch. After establishing a cardiopulmonary bypass (CPB), body temperature fell to 18°C. Then, CPB was stopped, the ascending aorta was clamped, and cardioplegic solution was continuously infused into the proximal ascending aorta. The distal ascending aorta was opened, and retrograde cerebral perfusion was initiated, maintaining a pressure around 15 mm Hg. First, the bottom of the brachiocephalic artery and left common carotid artery were excised as the "island" with a 10-mm rim around their ostia. This aortic island was sewn to the beveled end of a 16-mm collagen-impregnated woven vascular graft (Intervascular S.A., Cedex, France) with running 4-0 Prolene (Ethicon, Inc., Somerville, NJ) suture (Fig 2A).
After completing anastomosis, retrograde cerebral perfusion was stopped, and the brain was antegradely perfused via side-branch, 10-mm collagen-impregnated woven vascular graft, which had been sewn beforehand to the 16-mm vascular graft, then the left subclavian artery was clamped (Fig 2B). Second, the aortic arch was transected between the left common carotid artery and the left subclavian artery. A 26-mm collagen-impregnated woven vascular graft with a 10-mm side branch (commercially available in Japan; Intervascular S.A., Cedex, France) that was invaginated and the "Elephant trunk" segment (length 10 cm) were inserted into the stent graft that had been previously implanted (Fig 2C), and the doubled-up ridge of the inserted graft was aligned to the transected aortic edge (Fig 2D). Full-thickness suture was accomplished with 4-0 Prolene. After suturing, the invaginated segment was extracted, and the Elephant trunk segment was dilated with a balloon catheter under observation with trans-esophageal echocardiography (TEE), ensuring the Elephant trunk segment was fitted to the inside of the stent graft completely. The descending aorta was perfused via a 10-mm side branch of a 26-mm vascular graft, and rewarming was started. Third, the proximal end of the 26-mm vascular graft was sutured to the ascending aorta, and the open end of the 16-mm vascular graft was anastomosed to the ascending aorta by side-to-end maneuver, then all clamps except one for the left subclavian artery were removed. The left subclavian artery was suture-ligated and divided, and the transected distal end was anastomosed to the side branch of the 16-mm vascular graft. The patient was weaned from CPB smoothly, obtaining complete hemostasis. TEE showed blood flow neither within the false lumen nor into the space between the implanted stent graft and inserted vascular graft. The postoperative course was uneventful, and he was discharged from the hospital 14 days after surgery. Postoperative intravenous digital subtraction angiography revealed good configuration of the aorta, and no leakage to the false lumen through the space between the stent graft and Elephant trunk. Five months later, chest CT also revealed complete isolation of the false lumen and aneurysm between the left subclavian artery and the proximal end of the stent graft from the true blood stream, and the false lumen was reduced.
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Fig 1. Aortography performed before (A) and after (B) stent grafting. Primary entry detected 4 cm below the left subclavian artery (arrow). (C) Aortography performed 5 months after stent grafting. Aortic protrusion (asterisk) between the left subclavian artery and opacification of false lumen (arrow) were identified. Entry tear was detected at the site of the proximal end of the stent graft. (D) Intravenous digital subtraction angiography after surgical intervention revealed exclusion of aortic protrusion and obliteration of false lumen with elephant trunk segment. All neck arteries were reconstructed with a Y arch.
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Fig 2. Operative procedures. (A) Aortic "island" was sewn to the beveled end of 16-mm vascular graft. (B) After completion of anastomosis, the brachiocephalic artery and the left common carotid artery were perfused antegradely via side branch of 16-mm vascular graft. (C) Invaginated 26-mm vascular graft was inserted into the transected aorta. (D) Doubled-up ridge of inserted vascular graft was aligned to the edge of the transected aorta and a full-thickness suture was performed. (E) Repair complete.
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Comment
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Endovascular stent grafting is increasingly common worldwide. Many physicians agree that this new procedure is less invasive and as effective as conventional surgical grafting in selected patients. But once it fails, aggressive endovascular intervention or surgical operation is essential. Several surgical approaches are available in that situation.
The reasons why we chose mediansternotomy, not left thoracotomy, follow. First, because the aortic protrusion between the left subclavian artery and the proximal end of the implanted stent graft was thought to be degeneration of the aortic wall due to previous aortic dissection, it was unsuitable for the anastomotic site. Second, it was better to leave the left thoracic cavity untouched, because the patient had localized aortic dissection just below the diaphragm that may need surgical intervention in the future. Therefore, we approached the aortic arch and the proximal descending aorta via mediansternotomy, and developed a mediansternotomy operation.
The procedure employed is a modification and combination of the "Y arch" technique, reported by Galla and associates [1] and Elephant trunk technique, reported by Borst and associates [2]. The Y arch technique provides good cerebral protection if distal aortic anastomosis is expected to be problematic, because it takes less than 30 minutes for anastomosis between the aortic cap and vascular graft. After completion of anastomosis, neck arteries receive antegrade blood flow with sufficient pressure and flow volume. Another advantage is that it is possible to obtain good hemostasis at every anastomotic site, because all suture lines are visible with small traction of each vascular graft. In this reported case, we anastomosed the vascular graft for the neck arteries to the native ascending aorta to obtain good hemostasis. It might be unwise given the possibility of newly onset aortic dissection at the ascending aorta despite good hemostasis. Recently, we have made anastomoses to the vascular graft in the ascending aorta position under cardiac arrest. The original Elephant trunk technique was designed to prepare and facilitate the next stage of operation, in which a descending aorta replacement is needed. Therefore, the freely floated segment, per se, does not aim to exclude the aortic aneurysm or obliterate the entry to the false lumen. However, a report from the Hannover group is encouraging. They documented a case of thrombosed aneurysm with Elephant trunk, and additional operation was not necessary [3]. Palma and associates reported the use of Elephant trunk for surgical treatment of acute type B aortic dissection to seal the primary entry [4]. Moreover, we had a case of acute type A aortic dissection complicated with cardiac tamponade, and the primary tear was detected 5 cm distal from the left subclavian artery intraoperatively. We performed the Y arch technique and Elephant trunk technique, and the primary tear was obliterated with Elephant trunk, and the false lumen diminished (not presented). Therefore, we anticipate that Elephant trunk has greater potential than the freely floating graft in the aorta only. Moreover, given our knowledge of endoluminal stent grafting, although leakage might occur through the space between the implanted graft and aortic wall, it is possible to stop this with a stent graft. A similar operation to our case was reported previously [5], but our intention was exclusion of aortic aneurysm or obliteration of the entry with Elephant trunk. And, if necessary, complete exclusion could be performed with the stent grafting procedure. Furthermore, the Y arch technique offers safer brain protection and better hemostasis.
Recently, degeneration of the aorta wall after stent grafting repair in a cases of acute aortic dissection was reported [6]. We believe the surgical intervention presented here could be one option for failed or unsatisfactory endovascular stent grafting.
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References
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- Galla J.D., McCullough J.N., Griepp R.B. Aortic arch replacement for dissection. Operat Tech Thorac Cardiovas Surg 1999;4:58-76.
- Borst H.G., Walterbusch G., Schaps D. Extensive aortic replacement using "elephant trunk" prosthesis. Thorac Cardiovasc Surg 1983;31:37-40.[Medline]
- Borst H.G., Frank G., Schaps D. Treatment of extensive aortic aneurysms by a new multiple-stage approach. J Thorac Cardiovasc Surg 1988;95:11-13.[Abstract]
- Palma J.H., Almeida D.R., Carvalho A.C., Andrade J.C., Buffolo E. Surgical treatment of acute type B aortic dissection using an endoprosthesis (elephant trunk). Ann Thorac Surg 1997;63:1081-1084.[Abstract/Free Full Text]
- Konishi T., Higuchi K., Fukuta M., Takeda M., Akisima S., Fukuda S. Extended aortic replacement in acute dissection by the separated elephant trunk technique. Ann Thorac Surg 1999;67:1664-1668.[Abstract/Free Full Text]
- Kato N., Hirano T., Kawaguchi T., et al. Aneurysmal degeneration of the aorta after stent-graft repair of acute aortic dissection. J Vasc Surg 2001;34:513-518.[Medline]
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Abstract
Introduction
