Ann Thorac Surg 2005;80:318-320
© 2005 The Society of Thoracic Surgeons
Case report
Rescue Visceral Revascularization Without Direct Aortic Surgery to Treat Malperfusion Complicating Type B Aortic Dissection
Kenji Okada, MD*,
Taijiro Sueda, MD,
Kazumasa Orihashi, MD,
Katsuhiko Imai, MD,
Yuji Sugawara, MD,
Masaki Hamamoto, MD
Department of Cardiovascular Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
Accepted for publication January 22, 2004.
* Address reprint requests to Dr Okada, Department of Cardiovascular Surgery, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima734-8551, Japan (Email: kokada{at}hiroshima-u.ac.jp).
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Abstract
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A 75-year-old woman presented with superior mesenteric artery and celiac artery occlusion associated with acute type B dissection. Emergent bypass grafting by using the right gastroepiploic artery and the left radial artery for the superior mesenteric artery and the celiac artery was performed without bowel resection.
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Introduction
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Malperfusion of the visceral arteries is a potentially fatal complication of aortic dissection [1]. Proximal aortic repair, endovascular stent-grafting, and fenestration are controversial methods of treatment. We report successful bypass grafting by using arterial conduits for superior mesenteric artery and celiac artery occlusion associated with type B dissection.
A 75-year-old woman who had been treated for autogenous liver disease was referred to Hiroshima University Hospital with left back pain. Three weeks after admission, she experienced sudden dull abdominal pain in the evening. The following day, computed tomography demonstrated a type B dissection with an entry 1 cm distal to the origin of the left subclavian artery. The true lumen became gradually smaller in diameter and was interrupted just above the celiac artery. The celiac artery and the superior mesenteric artery (SMA) were occluded, and both renal arteries originated from the false lumen. The dissection extended to both common iliac arteries, and the pulse of the right femoral artery was extremely weak. The right and left ankle pressure indices were 0.6 and 0.9, respectively. The abdominal pain had gradually increased in severity. Laboratory data demonstrated that liver enzymes were in the normal range, but base excess serum levels were gradually increasing. An emergent operation was performed.
We planned to use the right gastroepiploic artery (GEA) and the left radial artery for the celiac artery and the SMA bypass grafts. A median laparotomy was performed. The color of the bowel and the liver was pale, although ascites were not found. The right external iliac artery (EIA) could be palpated, and the pulse was extremely weak. However, the left EIA was not dissected and could be easily palpated, and we decided to use the left EIA as an inflow site.
The left radial artery and the GEA were harvested simultaneously. The ileocolic artery was exposed and dissected out. The left EIA–ileocolic arterial bypass was performed through the mesojejunum with the conduit of the left radial artery. Then we attempted to anastomose the GEA to the left EIA through the mesocolon transversum and the mesojejunum. The length of the GEA was insufficient to reach the left EIA; therefore, saphenous vein was interposed between the GEA and the left EIA.
As soon as both bypass grafts had been completed, the color of the bowel and the liver turned red. At the beginning of the operation, the base excess serum level had fallen to –12 mEq/L but returned to normal levels immediately after revascularization. The operation was completed without bowel resection. During the operation, her blood pressure was managed within 120 mm Hg with a calcium antagonist.
The patient’s postoperative course was uneventful. The patient underwent extubation on postoperative day 2. Postoperative aortography showed patency of the two bypass grafts (Fig 1). The true lumen was still interrupted just above the celiac artery, and the two abdominal branches were perfused from both bypass grafts supplied the left EIA. After 7 months, this patient is in good condition, without abdominal angina or intermittent claudication.
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Fig 1. Postoperative angiogram demonstrating patent grafts. (EIA = external iliac artery; GEA = gastroepiploic artery; RA = radial artery; SV = saphenous vein.)
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Comment
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Intestinal necrosis resulting from visceral malperfusion is one of the most serious complications of aortic disease. Organ malperfusion is a significant predictor of early and late death. Since the first successful surgical treatment in 1954 [2], various surgical options, such as proximal aortic repair, percutaneous fenestration, stent-grafting, and extraanatomical bypass, have been attempted to reverse malperfusion from aortic dissections. Proximal aortic repair requires time to restart perfusion, and organ malperfusion may persist after proximal aortic repair despite the redirecting of blood flow into the true lumen. It is difficult to deploy a stent-graft at the entry site when the femoral arteries are diseased. Moreover, percutaneous balloon fenestration and extraanatomic bypass grafts are unreliable methods. As such, we performed direct surgical revascularization of aortic branches by using bypass grafting.
In this case, the left EIA was well perfused from the false lumen and was not dissected. Then, we used the left EIA as an inflow vessel. We thought that an arterial graft was most suitable in this case because there was a risk of kinking of the graft conduits. Accordingly, we planned to use arterial conduits for two bypass grafts. At the beginning of the operation, the GEA graft would be anastomosed directly to the left EIA, and retrograde blood flow would go back through the GEA graft to the celiac artery. The GEA graft was too short to anastomose the left EIA directly. Ultimately, we performed the GEA–left EIA bypass by using a saphenous vein graft.
Leke and colleagues [3] described their contemporary experience with a tailored surgical approach for the treatment of chronic mesenteric ischemia. They emphasized that the most important factors in prognosis were to determine the optimal site for the origin of the grafts, the conduit material, and the need for single-vessel or multiple-vessel revascularizations.
After the first disappointing experience more than 2 decades ago [4], the use of the radial artery in coronary artery bypass grafting was again proposed by Acar and colleagues in 1992 [5]. Since then, many groups have reported encouraging results with this alternative arterial conduit. Suma and associates first described coronary artery bypass grafting with the GEA in 1987 [6]. These two arterial conduits have been used widely for coronary artery bypass grafting; however, their use for visceral revascularization is not common.
Our report describes the use of the radial artery and the GEA as conduits for the visceral vessels. About 20 minutes were required to harvest the GEA and the radial artery, so use of the GEA and the radial artery does not result in a prolonged time for reperfusion of the vessels. In fact, with the use of the Harmonic ultrasonic scalpel (Ethicon EndoSurgery, Cincinnati, OH), harvesting time was of no concern. As such, the radial artery and the GEA are suitable alternative conduits for bypass grafting with SMA and celiac artery occlusion.
In cases of visceral ischemia with type B dissection, it is important to determine the optimal inflow site, because the inflow site will ultimately determine operative results. Dissected aorta and artery were not suitable. We think that the EIA is suitable as an inflow site because this vessel is most distal from the heart, which minimizes the possibility of dissection. Moreover, this vessel is bilateral and technically easy to expose. In the case of the dissected iliac artery, a short prosthesis was interposed between diseased iliac artery, then the conduit was anastomosed to the prosthesis.
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References
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- Okita Y, Takamoto S, Ando M, Morota T, Kawashima Y. Surgical strategies in managing organ malperfusion as a complication of aortic dissection Eur J Cardiothorac Surg 1995;9:242-247.[Abstract]
- DeBakey ME, Cooley DA, Creech O. Surgical consideration of dissecting aneurysm of the aorta Ann Surg 1955;142:586-612.[Medline]
- Leke MA, Hood DB, Rowe VL, Katz SG, Kohl RD, Weaver FA. Technical consideration in the management of chronic mesenteric ischemia Am Surg 2002;68(12):1088-1092.[Medline]
- Fisk RL, Brooks CH, Callaghan JC, Dvorkin J. Experience with the radial artery graft for coronary artery bypass Ann Thorac Surg 1976;21:513-518.[Abstract]
- Acar C, Jebra VA, Portoghese M, et al. Revival of the radial artery for coronary artery bypass grafting Ann Thorac Surg 1992;54:652-660.[Abstract]
- Suma H, Wanibuchi J, Terada Y, Fukuda S, Takayama T, Furuta S. The right gastroepiploic artery graftclinical and angiographic midterm results in 200 patients. J Thorac Cardiovasc Surg 1993;105:615-623.[Abstract]
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Abstract
Introduction
