Ann Thorac Surg 2004;78:e3-e5
© 2004 The Society of Thoracic Surgeons
Case report
An endovascular stent relieves celiac and mesenteric ischemia in acute aortic dissection
Pascal Leprince, MDa*,
Philippe Cluzel, MDa,
Nicolas Bonnet, MDa,
Romuald Izzillo, MDa,
Alain Pavie, MDa,
Iradj Gandjbakhch, MDa
a Departments of Cardiovascular Surgery and Radiology, Groupe Hospitalier Pitié-Salpétrière, Paris, France
Accepted for publication December 10, 2003.
* Address reprint requests to Dr Leprince, Service de Chirurgie Thoracique et Cardiovasculaire, Institut du C
ur, Groupe Hospitalier Pitié-Salpétrière, 47-83 Bd de l'Hôpital, 75013 Paris, France
e-mail: pascal.leprince{at}psl.ap-hop-paris.fr
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Abstract
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We report the case of a 63-year-old patient with bowel ischemia related to an acute type B dissection. The patient was successfully treated with a covered stent graft inserted at the level of the descending thoracic aorta.
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Introduction
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Ischemic complications related to dissection of the descending aorta can be devastating. In the acute phase, intimal flap fenestration can be lifesaving, allowing pressure equilibration between the true and false lumens. On the other hand, covered stent grafts are mostly used when the false lumen becomes enlarged or even ruptures. However, covering a proximal tear in the descending thoracic aorta also allows decreasing pressure in the false lumen [1]. We present the case of a patient with bowel ischemia related to an acute type B dissection.
A 63-year-old patient had recent onset of abdominal pain 18 days after an acute type B dissection. A computed tomographic scan showed an intimal tear in the descending thoracic aorta (Fig 1A).
At the level of the celiac and superior mesenteric arteries, the true lumen was almost completely occluded, leading to dynamic occlusion of the collaterals (Figs 1B, 1C), as described by Williams and colleagues [2]. The collateral arteries were not dissected, but the true lumen was compressed by the false lumen. The blood supply of the left and right renal arteries originated from the true lumen.
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Fig 1. Aortic computed tomographic scans made before treatment of the dissection showing (A) intimal tear at the level of the descending thoracic aorta, (B) dynamic occlusion of the celiac artery, and (C) the superior mesenteric artery because of high pressure in the false lumen. (arrowhead = false lumen; arrow = true lumen.)
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The patient was treated with a covered stent graft (32 mm in diameter, 101 mm in length) (Talent: Medtronic, Inc) inserted through the left common femoral artery. The 1-week computed tomographic scan showed occlusion of the intimal tear by the stent but incomplete thrombosis of the false lumen (Fig 2A).
Distal to the stent, the diameter of the true lumen increased, thus allowing better perfusion of the digestive arteries (Figs 2B, 2C). Perfusion of the renal artery remained unchanged. The patient experienced no complications and was discharged 3 days later with complete relief of pain. At 3 months, the false lumen was totally thrombosed (Fig 3A),
and the aortic diameter at the level of the celiac and superior mesenteric arteries was normal (Figs 3B, 3C).
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Fig 2. Aortic computed tomographic scans made 3 days after treatment with the covered stent graft showing (A) stent graft covering the intimal tear, although the false lumen remains perfused, (B) partial release of compression of the true lumen by the false lumen at the level of the celiac artery, and (C) superior mesenteric artery. (arrowhead = false lumen; arrow = true lumen.)
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Fig 3. Aortic computed tomographic scans made at 3 months showing (A) thrombosis of the false lumen, (B) shrinkage of the false lumen at the level of the celiac artery, and (C) superior mesenteric artery with restoration of normal aortic shape and diameter. (arrowhead = false lumen; arrow = true lumen.)
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Comment
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In acute aortic dissection, occlusion of an intimal tear with a covered stent graft is a safe and efficient method to release collateral artery dynamic occlusion [3].
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References
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- Kato N., Hirano T., Takeda K., et al. Treatment of aortic dissections with a percutaneous intravascular endoprosthesis: comparison of covered and bare stents. J Vasc Interv Radiol 1994;5:805-812.[Medline]
- Williams D.M., Lee D.Y., Hamilton B.H., et al. The dissected aorta: part III. Anatomy and radiologic diagnosis of branch-vessel compromise. Radiology 1997;203:37-44.[Abstract/Free Full Text]
- Dake M.D., Kato N., Mitchell R.S., et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340:1546-1552.[Abstract/Free Full Text]
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Abstract
Introduction
