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Ann Thorac Surg 2006;82:747-749
© 2006 The Society of Thoracic Surgeons

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Case report

Treatment of Acute Type A Dissection by Percutaneous Endovascular Stent-Graft Placement

^a Department of Cardiothoracic Surgery, University of Vienna Medical School, Vienna, Austria
^b Department of Interventional Radiology, University of Vienna Medical School, Vienna, Austria

Accepted for publication November 22, 2005.

^_* Address correspondence to Dr Zimpfer, Waehringer Guertel 18-20, Vienna, A-1090 Austria (Email: daniel.zimpfer{at}meduniwien.ac.at).

	Abstract

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Acute type A dissections are a life threatening condition requiring immediate surgical intervention to avoid aortic rupture or pericardial tamponade. Success of surgical intervention is markedly limited in those patients with advanced age, neurological deficits, and multiple co-morbidities at the time of treatment. We report the successful endovascular stent-graft treatment in a patient suffering from an acute type A dissection. Due to the presence of multiple comorbidities the patient was considered too high risk for surgical treatment.

	Introduction

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Endovascular stent-graft treatment has emerged as an alternative treatment option for various diseases of the descending aorta including aortic type B dissections and penetrating ulcers. So far, percutaneous endovascular stent-graft treatment of ascending aortic disease was only performed in patients with subacute type A dissections and penetrating ulcers. We report the successful percutaneous endovascular stent-graft treatment of an acute aortic type A dissection as the primary and sole treatment of a patient.

An 84-year-old man was admitted to our emergency department due to the onset of severe chest pain (6 hours previously). At the time of admission the patient had paraplegia develop without any signs of central nervous damage. Computed tomographic scan revealed an acute aortic type A dissection with an entry tear in the mid portion of the ascending aorta (Fig 1). After intensive care treatment and steroid bolus therapy, paraplegia completely dissolved [1]. Due to the patients advanced age, the development of intermittent paraplegia, and the presence of several co-morbidities (ie, diabetes, history of cerebrovascular and peripheral vascular disease, and chronic renal insufficiency), we refused to perform open surgery. Therefore the patient was presented with the option of stent-graft treatment. The patient agreed to undergo percutaneous stent-graft treatment through written and informed consent.

View larger version (165K): [in this window] [in a new window]   Fig 1. Oblique sagittal view of a computed tomographic scan at the time of diagnosis.

With the patient under general anesthesia, a custom made covered stent (Jotec, Hechingen, Germany) 46/85 mm was advanced into the ascending aorta through the right common femoral artery. Before deploying the stent-graft, the patient was paced to 180 bpm using a temporary ventricular pacemaker that was placed in the right subclavian vein. This was done to decrease cardiac output and consecutively minimize the risk of dislodging the stent-graft while deployment was undertaken. Thereafter the stent-graft was deployed distal to the coronary arteries (controlled by transesophageal echocardiography) and proximal to the brachiocephalic trunk. Completion angiography after stent-graft deployment revealed regular perfusion of the coronary arteries, complete exclusion of the dissection, as well as regular perfusion of the supra-aortic vessels (Fig 2). Aortic valve competence was confirmed by transesophageal echocardiography.

View larger version (151K): [in this window] [in a new window]   Fig 2. Digital subtraction completion angiography after stent-graft implantation.

View larger version (37K): [in this window] [in a new window]   Fig 3. Completion computed tomographic scans. (A) Oblique sagittal view. (B) Volume-rendered view.

	Comment

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The main benefit of this approach is its minimally invasive fashion, avoiding sternotomy as well as circulatory arrest. However, endovascular treatment bears the risk of catheter intervention-associated complications. Endovascular treatment of type A dissections further bears the risk of compromising the aortic valve, the coronary arteries, and the supraaortic vessels due to the special anatomy of the ascending aorta. In addition this treatment can only be offered to those patients with uncompromised aortic valve function (ie, no higher grade insufficiency) and an entry tear well above the coronary ostia in order to obtain a sufficient landing zone. Furthermore, the long-term durability of this approach is uncertain. Nevertheless this approach may add as an alternative treatment option in patients with multiple comorbidities and high surgical risk. A prerequisite before offering this approach to a broader patient population is exact knowledge on the needed stent-graft dimensions as there will be not enough time to tailor make a stent-graft in the majority of patients with acute type A dissections. Broader application of this technique will reveal its safety and efficacy, especially with regard to long-term outcome.

In conclusion, endovascular treatment of type A dissections is a promising option for those patients not suitable for conventional surgical repair and may add to the weaponry of cardiothoracic surgeons.

	References

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1. Steroids after spinal cord injuryNo authors listed Lancet 1990;336(8710):279-2804.[Medline]
2. Ehrlich MP, Schillinger M, Grabenwoger M, et al. Predictors of adverse outcome and transient neurological dysfunction following surgical treatment of acute type A dissections Circulation 2003;108(Suppl 1):II318-II323.[Medline]
3. Grabenwoger M, Fleck T, Czerny M, et al. Endovascular stent graft placement in patients with acute thoracic aortic syndromes Eur J Cardiothorac Surg 2003;23(5):788-793discussion 793.[Abstract/Free Full Text]
4. Zhang H, Li M, Jin W, Wang Z. Endoluminal and surgical treatment for the management of Stanford type A aortic dissection Eur J Cardiothorac Surg 2004;26(4):857-859.[Abstract/Free Full Text]
5. Ihnken K, Sze D, Dake, MD, et al. Successful treatment of a Stanford type A dissection by percutaneous placement of a covered stent graft in the ascending aorta J Thorac Cardiovasc Surg 2004;127(6):1808-1810.[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): Daniel Zimpfer Martin Czerny Ernst Wolner Michael Grimm Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Zimpfer, D. Articles by Grimm, M. Search for Related Content PubMed PubMed Citation Articles by Zimpfer, D. Articles by Grimm, M. Related Collections Great vessels