Ann Thorac Surg 2004;78:1072-1075
© 2004 The Society of Thoracic Surgeons
Case report
Stent-graft placement combined with percutaneous fenestration for the treatment of aortic dissection in a patient at risk of developing renal ischemia
Noriyuki Kato, MDa,*,
Tadanori Hirano, MDc,
Masaki Ishida, MDa,
Uhito Yuasa, MDd,
Takatsugu Shimono, MDb,
Kan Takeda, MDa
a Radiology, Matsusaka General Hospital, Mie, Japan
b Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, Mie, Japan
c Department of Radiology, Matsusaka General Hospital, Mie, Japan
d Department of Thoracic and Cardiovascular Surgery, Mie Central Hospital, Mie, Japan
Accepted for publication July 3, 2003.
* Address reprint requests to Dr Kato, Department of Radiology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514, Japan
kato{at}mri-gw.medic.mie-u.ac.jp
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Abstract
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A 51-year-old man, suffering from an aortic dissection with the entry tear in the descending thoracic aorta, underwent replacement of the ascending aorta and aortic arch with resection of the entry tear. Although the false lumen of the descending thoracic aorta was thrombosed after surgery, redissection developed in the descending aorta 2 months later. Percutaneous fenestration was performed before stent-grafting because it was judged that there was a significant risk of left renal ischemia. Entry closure with a stent-graft was performed successfully and no renal ischemia developed. The patient is doing well at 1 year after the procedure.
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Introduction
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Stent-graft repair has become a popular therapeutic approach in patients with a wide range of aortic diseases. Among the procedures performed, entry closure with endovascular stent-grafting is now recognized as an attractive alternative to surgical intervention for the treatment of patients with aortic dissection. However, in patients in whom some of the aortic branches are totally supplied by the false lumen, endovascular stent-grafting can be a challenge because entry closure may lead to ischemia or infarction of the organs supplied by these branches. In this report we describe our experience with entry closure, combined with percutaneous fenestration, for the treatment of aortic dissection in a patient in whom the left renal artery was supplied by the false lumen.
A 51-year-old man, who was diagnosed as having a Stanford type A aortic dissection with the entry tear in the descending thoracic aorta, underwent graft replacement of the ascending aorta and the aortic arch as well as resection of the entry tear. His postoperative course was uneventful and thrombosis of the false lumen of the descending thoracic aorta was confirmed by follow-up computed tomography (CT) performed 1 month after the surgical procedure.
However, CT performed 2 months later showed the development of a new false lumen which was thought to arise from the distal anastomotic site. It also showed that there were two false lumens; ie, the newly developed one and the original one at the abdominal aorta. Although the patient received antihypertensive medication during the follow-up period, the diameter of the descending thoracic aorta expanded from 42 mm immediately after graft replacement to 50 mm on follow-up CT performed 6 months later. Since the rate of expansion was significant, he was sent to us for endovascular treatment. Computed tomography showed that the superior mesenteric artery arose from the true lumen. The celiac artery and the right renal artery arose from the left-sided and the right-sided false lumen, respectively. However, a natural fenestration, which was formed by tears at the origins of both arteries, was clearly demonstrated. On the other hand, although the left renal artery arose from the left-sided false lumen, no fenestration was seen.
Preoperative aortography showed the same findings as CT; ie, that the superior mesenteric artery was supplied by the true lumen. Although the celiac artery and the right renal artery arose from the false lumen, they were clearly depicted by the blood flowing through the fenestration from the true lumen. However, even aortography performed with a pigtail catheter placed at the level of the renal artery orifice failed to clearly show the left renal artery. Since it was felt that entry closure with a stent-graft might result in left renal ischemia, creation of a fenestration was considered mandatory in this patient. At 9 months after graft replacement, he underwent a percutaneous fenestration procedure. A catheter was placed with the tip facing forward into the remnant of the left renal orifice after preliminary aortography. Test injection through the catheter showed very faint opacification of the false lumen (Fig 1). Then, the proximal end of the wire was advanced into the catheter and was pushed into the false lumen. Balloon dilatation was performed with a balloon catheter 12 mm in diameter, which was advanced along the wire after the catheter was confirmed to have entered the false lumen through the fenestration. The left renal artery was only faintly visualized in aortography performed after completion of the procedure due to the brisk blood flow from the false lumen. One month later, the patient underwent stent-graft placement under general anesthesia. Expanded polytetrafluoroethylene-covered Z-stents were used as the stent-grafts. A minor type I endoleak disappeared completely after balloon dilatation of the device (Fig 2). The left renal artery was clearly seen in aortography performed after completion of the procedure (Fig 3). Computed tomography performed 1 month later showed complete thrombosis of the false lumen and good opacification of the left kidney. The patient is doing well at 1 year of follow-up.
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Fig 1. (Left) Image showing test injection with the catheter tip catching the remnant (arrow) of the fenestration at the origin of the left renal artery. The false lumen is faintly opacified. (Right) Image obtained during balloon dilatation of the fenestration.
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Fig 2. (Left) Aortography before stent-grafting shows the entry tear (arrow) at the anastomotic site and the large false lumen. (Right) Aortography after stent-grafting shows complete closure of the entry tear.
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Fig 3. (Left) Preoperative aortography fails to clearly depict the left renal artery or the left-sided false lumen. (Right) Postoperative aortography clearly shows the left renal artery (arrow) as well as the left-sided false lumen (arrowhead).
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Comment
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The efficacy of stent-graft repair in both acute and chronic aortic dissections is now widely accepted [1, 2]. There were no deaths or complications associated with the procedure in the series of Dake and colleagues or the series of Nienaber and colleagues. However, it is well known that there are some patients in whom the aortic branches are supplied solely by the false lumen. In chronic dissection, if reentry develops in a branch vessel, the intimal flap may fuse to the opposite wall of the vessel. As a result, the branch becomes totally dependent on the blood flow from the false lumen. Special considerations, including intentional double-barrel aorta below the site of graft replacement, are required in such cases to avoid ischemic complications when surgical intervention is performed [3]. Similar techniques should be considered mandatory even when endovascular procedures are employed.
Percutaneous fenestration is mainly performed in cases with dynamic involvement of the aortic branches, and its safety and efficacy have been demonstrated in several studies [4, 5]. Unlike the cases described in these earlier studies, we created a fenestration before any symptoms developed. Preliminary angiography and CT showed no communication between the true and false lumens at the level of the origin of the left renal artery. It was therefore felt that complete closure of the entry tear could potentially lead to renal infarction. Since the dissection had not extended into the left renal artery, there must have been a natural fenestration. Indeed, the catheter caught the remnant of the fenestration and test injection through the catheter showed slight opacification of the false lumen during percutaneous creation of the fenestration. Based on the above findings, it was thought that the natural fenestration became smaller due to some fibrotic process during the period of transition from acute to chronic dissection.
Theoretically, other methods could have been selected. For example, we could have created a fenestration after confirming the absence of flow into the left renal artery following entry closure. The fact that there was a communication between the two lumens at the level of the celiac artery might support this strategy. Indeed, we discussed this option with the surgeons preoperatively. However, we elected not to perform such a procedure because we were concerned that it might be too time-consuming, resulting in a delay in the reperfusion of the left kidney by percutaneous fenestration.
In conclusion, stent-graft placement combined with percutaneous fenestration may prove to be a safe, effective, and organ-saving method for the treatment of patients with aortic dissection, when aortic branches are totally supplied by the false lumen and there is a significant risk of organ ischemia after percutaneous entry closure.
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References
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- Dake MD, Kato N, Mitchell RS, 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]
- Nienaber CA, Fattori R, Lund G, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med. 1999;340:1539–1545[Abstract/Free Full Text]
- Miller DC. Surgical management of aortic dissections: indications, perioperative management, and long-term results. Doroghazi RM, Slater EE. Aortic dissection. New York: McGraw-Hill; 1983. p. 193–243
- Slonim SM, Nyman URO, Semba CP, Miller DC, Mitchell RS, Dake MD. True lumen obliteration in complicated aortic dissection: endovascular treatment. Radiology. 1996;201:161–166[Abstract/Free Full Text]
- Williams DM, Lee DY, Hamilton BH, et al. The dissected aorta: percutaneous treatment of ischemic complications-principles and results. J Vasc Intervent Radiol. 1997;8:605–625[Medline]
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Abstract
Introduction
