Ann Thorac Surg 2002;74:2189-2190
© 2002 The Society of Thoracic Surgeons
Case report
Treatment of a fistula at the distal anastomosis after Bentall operation with endoluminal covered stent
Daniel Roux, MDa*,
Laurent Brouchet, MDa,
Hervé Rousseau, MDa,
Tamer Elghobary, MDa,
Yves Glock, MD, PhDa,
Gérard Fournial, MDa
a Departments of Cardiovascular Surgery and Radiology, Toulouse-Rangueil University, Hôpital de Rangueil, Toulouse, France
Accepted for publication June 28, 2002.
* Address reprint requests to Dr Roux, Départment de Chirurgie Cardiovasculaire, Hôpital de Rangueil, 1 Ave Jean-Poulhés, F-31403 Toulouse Cedex 4, France
e-mail: fournial.g{at}chu-toulouse.fr
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Abstract
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A 25-year-old Marfan patient was operated on for an acute type A aortic dissection that was complicated twice by false aneurysms at the distal suture line. At the third episode a covered endoprosthesis was inserted in the ascending aorta between the coronary ostia and the inominate artery. The postoperative course was uneventful and a control computed tomographic scan showed complete occlusion of the false aneurysm.
This attractive technique should be considered versus an open-heart operation in selected patients.
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Introduction
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The occurrence of a false aneurysm has been described in 2% to 3% of patients after surgical treatment of acute aortic type A aortic dissection. Some false aneurysms may leak actively threatening the patient’s life; the introduction and rapid spread of endovascular stent grafts for the thoracic aorta has led several teams, including ours, to use them in these patients.
A 25-year-old Marfan patient was admitted to our department with acute chest pain and loss of consciousness. Echocardiographic study revealed massive pericardial effusion, grade IV aortic insufficiency and Type A acute aortic dissection. He was brought to the operating room where a Bentall procedure with a composite Medtronic Hall Kaster n° 31 graft (Medtronic, Minneapolis, MN) was inserted. The distal anastomosis was performed beyond the intimal tear at a mid portion of the ascending aorta, although the aortic tissues seemed macroscopically pathologic. The postoperative course was uneventful [1]. Three months later this patient was reoperated for a large false aneurysm compressing the superior vena cava and right pulmonary artery. At operation during circulatory arrest the entry of the false aneurysm was found at the distal suture line of the Dacron prosthesis (Medtronic, Minneapolis, MN). The fistula was closed using three interrupted sutures with Teflon pledgets (Intervascular, La Ciotat, France). The postoperative course was again uneventful [2]. Five years later he was admitted to our department for acute chest pain. A computer tomographic scan (Fig 1)
revealed another false aneurysm occurring at the site of the distal anastomosis of the Dacron graft (Medtronic). The collar of this false aneurysm, however, was small enough to consider an endoluminal covered stent of this area with the radiologists [3]. Under general anesthesia, the right femoral artery was exposed and a Medtronic Talent n° 32 covered stent (Medtronic) was introduced and placed between the coronary ostia and the inominate artery (Fig 2).
The postoperative course was unventful and a control computed tomographic scan showed occlusion of the collar with a reduction in the diameter of the false aneurysm (Fig 3).
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Fig 1. Computed tomographic scan with contrast. The arrow points to the fistula between the ascending aorta (A), and the false aneurysm (B).
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Fig 3. Control computed tomographic scan showing the disappearance of the fistula between the ascending aorta (with the covered prosthesis) (A) and the false aneurysm (B).
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Comment
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Marfan syndrome is a genetic disease characterized by progressive degeneration of the elastic fibers of the media of the aortic wall [4]. It remains a complex aortic disease that requires a global approach when the patient becomes symptomatic. These patients generally present with acute aortic dissection for which the classic approach is to resect the intimal tear from which the false aortic lumen originates. Unfortunately, this approach leaves pathologic aortic tissues that may be the source of other aortic accidents in place. Our current approach in such patients includes aortic root replacement according to the Bentall procedure associated with an elephant trunk technique for the distal anastomosis [5]. Our patient did not benefit from this approach and was therefore treated by a conventional method, which developed early and mid-term postoperative complications. With regard to the third event in this patient, an open heart reoperation was balanced against an endoluminal procedure because the collar was small and the remaining aorta was macroscopically normal. In addition, the endoluminal approach had become, in our experience, the treatment of choice for thoracic and abdominal aortic aneurysms [3]. Finally, a third sternotomy was a risk.
Positioning the endoprosthesis between the coronary ostia and the inominate artery was quite difficult to avoid obstructing one of these vital vessels. After careful examination of different radiologic plans and with electrocardiographic and right radial arterial monitoring, the prosthesis was inserted into an adequate position that completely occluded the false aneurysm.
Endoprostheses recently gained more popularity because the device avoids an operation and offers a valuable solution for complex lesions. Although it seems important to keep in mind that other aortic events may surface during follow-up, particulary in Marfan patients, endoluminal treatment remains an attractive and quite simple option for complex problems [6].
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References
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- Gott V.L., Cameron D.E., Alejo D.E., et al. Aortic root replacement in 271 Marfan patients: a 24-year Experience. Ann Thorac Surg 2002;73:438-443.[Abstract/Free Full Text]
- Henriques J.P.S., de la Riviere A.B., Shepens M.A.A.M., et al. Percutaneous occlusion of the entry to a leaking false aneurysm after ascending aortic replacement for aortic dissection type A facilitating surgical repair. Eur J Cardiothorac Surg 1997;11:381-383.[Abstract]
- Rousseau H., Soula P., Perreault P., et al. Delayed treatment of traumatic rupture of thoracic aorta with endoluminal covered stent. Circulation 1999;99:498-504.[Abstract/Free Full Text]
- McKusick V.A. Cardiovascular aspects of Marfan syndrome: heritable disorder of connective tissue. Circulation 1955;11:321-342.[Medline]
- Crawford E.S., Kirklin J.W., Naftel D.C., et al. Surgery for acute dissection of ascending aorta. Should the arch be included?. J Thorac Cardiovasc Surg 1992;104:46-59.[Abstract]
- Pansini S., Gagliardotto P.V., Pompei E., et al. Early and late risk factors in surgical treatment of acute type A aortic dissection. Ann Thorac Surg 1998;66:779-784.[Abstract/Free Full Text]
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Abstract
Introduction
