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Ann Thorac Surg 2003;75:1967-1969
© 2003 The Society of Thoracic Surgeons

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Case report

Acute retrograde aortic dissection during endovascular repair of a thoracic aortic aneurysm

^a Departments of Cardiac and Vascular Surgery, Academic Hospital, Free University of Brussels, Brussels, Belgium

Accepted for publication November 27, 2002.

^* Address reprint requests to Dr Bethuyne, Academic Hospital, Free University of Brussels, Department of Cardiac Surgery, Laarbeeklaan, 101, 1090 Brussels, Belgium, noella.bethuyne.pi.be

	Abstract

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Endovascular aneurysm exclusion represents a valuable alternative treatment for descending thoracic aortic aneurysms. Although the minimally invasive character of this procedure is obvious, major complications are possible. We report a 77-year-old male who developed acute retrograde dissection of the aortic arch and ascending aorta during endovascular stent-grafting of a descending aortic aneurysm. Emergent open surgical repair provided a successful outcome.

	Introduction

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Endovascular stent-grafting has emerged as a less invasive therapeutic alternative to treat aneurysms of the descending thoracic aorta [1, 2]. Growing experience in endovascular surgery as well as continuous refinements in prosthetic equipment have increased the feasibility of this novel technique in selected patients. Although early results are comparing favorably with those of conventional open surgery, several procedure-related complications, such as stent-graft dislodgement, arterial injury, stroke, embolization, paraplegia, and left arm ischemia, have been described [3].

This report presents a case of acute retrograde aortic dissection as a complication of endovascular stent-graft repair of a descending aortic aneurysm, necessitating urgent surgical replacement of the ascending aorta and aortic arch.

A 77-year-old male presented atypical chest and back pain on admission. Physical examination revealed a systolic heart murmur, suggesting mild mitral regurgitation. Blood pressure was 150/70 mm Hg symmetrically at both arms. All major peripheral arteries were pulsatile. His medical history included surgical resection of an abdominal aneurysm with implantation of an aorto-iliac Dacron graft 8 years earlier (DuPont Pharmaceuticals, Wilmington, DE), arterial hypertension, hypercholesterolemia, and noninsulin dependent diabetes. Chest roentgenogram revealed a prominent silhouette in the left hemithorax, evocating an enlarged descending aorta. A thoracic computed tomographic (CT) scan disclosed a large descending aortic aneurysm with a maximal diameter of 80 mm without rupture or dissection. Further investigation by angiography and spiral CT scanning confirmed the diagnosis of a fusiform atherosclerotic aneurysm, starting 3-cm distal to the left subclavian artery orifice and extending downwards to the diaphragmatic hiatus. Based on the anatomic findings, an endovascular treatment was considered.

Under general anesthesia, a Talent LPS endoprosthesis (Medtronic Inc, Minneapolis, MN) was introduced through open right femoral artery access. The stent-graft itself consisted of self-expanding nitinol stent springs, covered by a woven Dacron graft with an uncovered proximal (FreeFlo^TM) and distal (Bare Spring^TM) [Medtronic Inc, Minneapolis, MN] anchoring design. The diameter of the stent-graft was 42 mm, and the total length of the device was 130 mm. It was decided to overstent the left subclavian artery origin with the proximal uncovered part of the stent-graft to create a more adequate proximal anchoring zone affording a tight endoseal. A steep angle of 68 degrees between the aortic arch and descending aorta rendered the deployment of the first endoprosthesis hazardous, but further insertion of two additional stent-grafts excluded the aneurysm completely.

However, completion angiography indicated an intimal flap starting from the most proximal stent-graft and dissecting retrograde throughout the arch and ascending aorta (Fig 1). Because of the potentially lethal extension of the dissection, immediate surgical repair was undertaken.

View larger version (125K): [in this window] [in a new window]   Fig 1. Digital substraction angiography of the stent-graft repair with its proximal uncovered end overstenting the left subclavian artery orifice (white arrow) and the intimal dissection extending retrograde to the ascending aorta (black arrow).

The postoperative course was complicated by a stroke with right-sided hemiparesis that fully recovered within 2 weeks.

Doppler examination revealed normal flow through the carotid vessels. At discharge, 8 weeks after surgery, the patient was clinically doing well. Computed tomography confirmed a satisfactory repair of the ascending aorta and aortic arch, with complete exclusion of the descending aortic aneurysm and thrombosis of the periprosthetic lumen (Fig 2).

View larger version (82K): [in this window] [in a new window]   Fig 2. Computed tomographic scan 8 weeks after endovascular and open surgical repair illustrating complete thrombosis of the aortic aneurysmal sac.

	Comment

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Recently, endovascular techniques have offered a less invasive alternative to treat this condition, aiming the reduction of operative risk and perioperative morbidity [3]. Accurate stent-graft repair requires vascular access of sufficient size, limited tortuosity, and a suitable aneurysm morphology. However, although initial clinical results are promising, demonstrating the greatest benefit in the high-risk population, this rapid evolving modality needs further assessment to truly define its long-term outcome [1, 2].

Endovascular treatment of descending aortic disease has been associated with some major complications [3]. Acute aortic dissection during endovascular stent-grafting of the thoracic aorta has so far been reported once, occurring in an attempt to exclude the primary intimal tear of an acute type B aortic dissection [6]. We might expect that the fragile nature of the intima in this acute pathology predisposes to this sort of problems.

In our patient, presenting a chronic atherosclerotic aneurysm, which suggests a more solid aortic wall consistence, we believe that the stiffness of the stent-graft device with its aggressive anchoring designs and its limited angulation capacity might have initiated the intimal tear. Undoubtedly, the impact force during stent-graft deployment as well as the hemodynamic shear stress on the aortic wall has promoted extension of the dissection. This complication most likely reflects the inability of the too rigid stent-graft device to accommodate to the curved geometry of the distal aortic arch, especially when the angulation exceeds 60 degrees.

Therefore, further refinements should be directed towards lower profile, more flexible, and less traumatic stent-grafts and delivery systems. To minimize aortic arch injury, the proximal stent should be fully covered, but solid enough to provide a tight circumferential seal. Additionally, proper patient selection, based on specific anatomic landmarks, remains a major key point in the prevention of this kind of life-threatening complications.

	References

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1. Dake M.D., Miller D.C., Semba C.P., Mitchell R.S., Walker P.J., Liddell R.P. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729-1734.[Abstract/Free Full Text]
2. Mitchell R.S., Miller D.C., Dake M.D., Semba C.P., Moore K.A., Sakai T. Thoracic aortic aneurysm repair with an endovascular stent graft: the "first generation". Ann Thorac Surg 1999;67:1971-1974.[Abstract/Free Full Text]
3. Greenberg R., Resch T., Nyman U., et al. Endovascular repair of descending thoracic aortic aneurysms: an early experience with intermediate-term follow-up. J Vasc Surg 2000;31:147-156.[Medline]
4. Coady M.A., Rizzo J.A., Hammond G.L., Kopf G.S., Elefteriades J.A. Surgical intervention criteria for thoracic aortic aneurysms: study of growth rates and complications. Ann Thorac Surg 1999;67:1922-1926.[Abstract/Free Full Text]
5. Svensson L.G., Crawford E.S., Hess K.R., Coselli J.S., Safi H.J. Variables predictive of outcome in 832 patients undergoing repairs of the descending thoracic aorta. Chest 1993;104:1248-1253.[Free Full Text]
6. Totaro T., Miraldi F., Fanelli F., Mazzesi G. Emergency surgery for retrograde extension of type B dissection after endovascular stent graft repair. Eur J Cardiothorac Surg 2001;20:1057-1058.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jacques P. Goldstein Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bethuyne, N. Articles by Goldstein, J. P. Search for Related Content PubMed PubMed Citation Articles by Bethuyne, N. Articles by Goldstein, J. P.