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Ann Thorac Surg 2004;77:317-319
© 2004 The Society of Thoracic Surgeons
a Chirurgie Vasculaire, Hôpital Cardiologique, Lille, France
Accepted for publication April 29, 2003.
* Address reprint requests to Dr Haulon, Chirurgie Vasculaire, Hôpital Cardiologique, CHRU de Lille, 59037 Lille Cedex, France
e-mail: s-haulon{at}chru-lille.fr
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A 47-year-old woman was admitted to an emergency department for thoracic trauma after a severe car accident in 1999. Because she had significant thoracic pain and left pleural effusion was seen on the chest radiograph, she underwent a contrast-enhanced spiral computed tomographic scanning. Images revealed a type B aortic dissection, with no evidence of traumatic rupture. No thoracic computed tomographic scan before the accident was available. Therefore, we could not conclude whether the dissection was related to the trauma. The primary entry tear was located at the isthmus; dissection extended to the infrarenal abdominal aorta without involving the iliac arteries, and the reentry tear was located in the aortic bifurcation. The maximum diameter of the descending thoracic aorta was 25 mm. No radiologic evidence of atherosclerotic disease in the aorta was found. Considering the patient presented with no clinical or radiologic sign of dissection complication, she was discharged on medical treatment, and computed tomographic scanning controls every 6 months were scheduled.
Two years later, the patient complained of persistent back and abdominal pain and gastrointestinal claudication. Further computed tomographic images revealed a patent false lumen with compression of the true lumen. The maximum aortic diameter was 35 mm. The true lumen supplied the left renal artery, the celiac trunk, and the superior mesenteric artery. Because of the symptoms suggestive of aortic branch ischemia, aortic repair was scheduled. She was initially scheduled to undergo an open surgical repair but before the procedure opted for an endovascular approach. The choice of stent grafting before fenestration was based on the presence of a single entry tear; indeed, covering this entry by an endovascular device was supposed to remove the dynamic compression of the true lumen by the false lumen. A thoracic endovascular graft (diameter, 26 mm; length, 130 mm; Talent; Medtronic Ltd, Fort Lauderdale, FL) was implanted during general anesthesia. At the beginning of the procedure, a guidewire was placed into the right renal artery from a true lumen access, through a fenestration of the dissection flap. Therefore, stenting of this artery could be performed in case of impaired right kidney perfusion after stent graft implantation. The device was inserted in a retrograde fashion through a right femoral artery arteriotomy, using a 24F introducer sheath. The delivery system was advanced through the right iliac limb with difficulty, but the stent graft could be deployed in the intended thoracic position. Intraoperative angiography revealed a successful sealing of the primary entry tear and a patent left subclavian artery, but also a rupture of the right common iliac artery. The patient was immediately converted to a right retroperitoneal approach, and a bypass graft between the right common iliac artery and the common femoral artery was performed.
Twelve days later, the patient developed chest pain radiating to the back. Electrocardiogram and cardiac enzymes were normal. An emergent computed tomographic scan revealed an acute type A dissection (Fig 1). The patient was operated on using hypothermic (25°C) cardiopulmonary bypass and antegrade cerebral perfusion through the right axillary artery. Once opened, no entry tear was identified in the ascending aorta. However, the proximal uncovered stent of the endovascular graft had created a tear in the aortic wall, opposite of the left common carotid ostium, resulting in a retrograde type A dissection. The primary entry tear of the type B dissection was excluded from the true lumen flow by the covered portion of the endovascular graft. The ascending aorta and proximal arch were replaced with a polyethylene terephthalate fiber graft. The patient recovered uneventfully.
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However, endovascular treatment of the descending thoracic aorta is associated with several complications directly related to the stent graft or as a result of manipulations of delivery systems within iliofemoral arteries, the abdominal and thoracic aorta, and aortic arch.
The most common acute life-threatening complication of endovascular repair of the descending thoracic aorta was reported to be iliac rupture as a result of large sheaths introduced through narrow arteries. Iliofemoral injuries during arterial access can occur during the introduction or retrieval of the device. This technical failure appears mostly in patients with small, calcified, atherosclerotic, and tortuous iliofemoral arteries. The incidence of this complication has been reported with rates up to 2.7% after endovascular repair of type B dissection. These rates are slightly higher than during endovascular repair of other aortic diseases, such as degenerative aneurysm, perforating ulcer, and traumatic rupture of isthmus, and seem to be caused by the fragility of the arterial wall [4–6]. Isolated cases of aortic rupture have also been reported.
The mechanism of the acute iatrogenic type A dissection we report was clearly identified at the time of open surgery. The stent may exert a pulsatile pressure on the intima through radial force and blood flow, and cause intimal defects. Although rare, we believe that iatrogenic type A aortic dissection is underreported. Indeed, some unexplained myocardial infarctions, aortic ruptures, and aneurysmal degeneration occurring after endovascular procedures could be related to this complication. Intramural hematoma of the arch after endovascular treatment are also probably underestimated, owing to diagnosis difficulties.
To avoid iatrogenic dissection during endovascular graft implantation, the position of the guidewire in the true lumen should always be controlled, and the introducer sheath and the endovascular graft itself should be the most atraumatic and flexible to match the angulation of the thoracic aorta. Whenever possible, endovascular repair of the aortic dissection should be delayed to allow fibrotic reorganization of the intimal flap.
Although endovascular grafting is apparently associated with less morbidity and mortality, potentially lethal complications, both acute and delayed, may arise. Great care should be given in the indications to minimize the morbidity related to endovascular repair.
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This article has been cited by other articles:
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  Z. H. Dong, W. G. Fu, Y. Q. Wang, D. Q. Guo, X. Xu, Y. Ji, B. Chen, J. H. Jiang, J. Yang, Z. Y. Shi, et al. Retrograde Type A Aortic Dissection After Endovascular Stent Graft Placement for Treatment of Type B Dissection Circulation, February 10, 2009; 119(5): 735 - 741. [Abstract] [Full Text] [PDF]
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