Ann Thorac Surg 2006;82:1523-1525
© 2006 The Society of Thoracic Surgeons
Case Reports
Iatrogenic Type A Dissection After Attempted Stenting of a Descending Aortic Aneurysm
Ruoyu Zhang, MDa,*,
Theo Kofidis, MDa,
Stefan Baus, MDb,
Uwe Klima, MD, PhDa
a Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
b Division of Radiology, Hannover Medical School, Hannover, Germany
Accepted for publication February 2, 2006.
* Address correspondence to Dr Zhang, Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Carl-Neuberg Str. 1, 30625 Hannover, Germany (Email: zhang.ruoyu{at}mh-hannover.de).
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Abstract
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This case demonstrates an iatrogenic acute retrograde type A dissection of the aortic arch and ascending aorta during elective endovascular stenting of a proximal descending aortic aneurysm. This devastating complication necessitated emergent surgery with unfavorable postoperative outcome. Other than the known causes, the described retrograde type A dissection resulted from guidewire manipulation and iatrogenic creation of a false lumen, which was erroneously dilated and stented.
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Introduction
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Endovascular graft repair is a possible therapeutic option for the treatment of descending aortic aneurysm [1]. Retrograde aortic dissection is a rare, but fatal complication that has been reported as a result of aortic injury induced by the stent-graft itself [2–5]. We describe a guidewire induced iatrogenic acute retrograde type A dissection during elective endovascular stent-graft repair. Waiver of patient consent was permitted by the institutional review board.
A 65-year-old woman was admitted to the hospital due to a progressive true aneurysm of a 1.5-cm diameter in the proximal descending aorta, 2 cm distal to the origin of the left subclavian artery. Due to the history of concomitant pulmonary emphysema and cerebral insult, as well as pulmonary embolism, the patient had chosen the endovascular stent-graft procedure. The pre-interventional computed tomography and angiography revealed a marked kinking of the aortic arch at the junction with the descending aorta, as well as truncus bicaroticus as an anatomic variant.
An Excluder-Gore stent-graft system (Gore & Assoc, Flagstaff, AZ) was used for the procedure. The procedure was performed by an experienced team (with more than 300 endovascular stent repairs of thoracic aneurysm in the past 3 years) made up of an interventional radiologist, a vascular surgeon, and an anesthesiologist in an angiographic suite with the patient under general anesthesia. After surgical exposure of the right common femoral artery (there was marked kinking of the left common femoral artery), a pigtail catheter was advanced into the ascending aorta over a Terumo guidewire (Radiofocus, Terumo, Tokyo, Japan) followed by a control angiography. A supplementary control catheter was introduced through the right brachial artery. Subsequently the Terumo guidewire was exchanged for a stiff Amplatz guidewire (Boston Scientific, Natick, MA) that was passed beyond the aneurysm. Over this guidewire the introducer sheath was placed into the infrarenal abdominal aorta. The delivery catheter, along with the stent-graft was subsequently inserted into the aorta. Until then the position of guidewire and the stent-graft was frequently controlled by the supplementary control catheter. The guidewire was seemingly projected inside the lumen of the aorta (Fig 1A). However, in the further course of the stent-graft placement, the angiography controls revealed that the guidewire was projected observably outside the lumen of the aorta (Fig 1B). Unfortunately, this process escaped the proper diagnosis, and the stent-graft was deployed closely distal to the origin of brachiocephalic trunk. The subsequent angiographic imaging through the pigtail catheter over the stent-graft could not demonstrate the supraaortic arteries, which were visible after the angiography through the right brachial artery indeed (Figs 1C, 1D). The stent-graft had been erroneously placed in the false lumen in the aortic arch.
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Fig 1. (A) The guidewire was seemingly projected inside the lumen of the aorta. (B) The guidewire was now observably projected outside the lumen of the aorta. (C) After the deployment of the stent-graft, the angiography control through the pigtail catheter over the stent-graft could not demonstrate the supra-aortic arteries. (D) However, the supra-aortic arteries were visible in the subsequent angiography through the right brachial artery.
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The hemodynamics of the patient became unstable within a short time. As the patient was transfered to the operating room, she had a mean arterial pressure of 40 mm Hg and a systolic pressure of 60 mm Hg under a high dosage of catecholamines. A cardiothoracic surgeon with excellent experience of aortic surgery was able to immediately join the emergent surgery. After the median sternotomy the retrograde type A dissection was evidenced. The cardiopulmonary bypass was then established after the aortic arch and the right atrium were cannulated. The patient underwent systemic hypothermia (27°C) and circulatory arrest with antegrade cerebral perfusion. The hypoxic duration was approximately 30 minutes. The stent-gaft was located in a false lumen distal to the origin of the brachiocephalic trunk. An entry was not found in the proximal aortic arch. The dissection reached to the aortic valve commissures. After removing the stent-graft, Surgical Glue (C. R. Bard, Saint-Etienne, France) was used to attach the vessel layers in the dissected aortic arch. The ascending aorta and proximal arch were replaced with a 24-mm Dacron prosthesis. In addition, as the type A dissection was recognized, the introducer system in the right external iliac artery was left in situ. After the beginning of the emergency surgery, we tried to remove it simultaneously with the median sternotomy. However the withdrawal of the unrecognized folded introduction sheath led to unintended total extraction of the right external iliac artery, which necessitated the emergent performance of an iliac-femoral bypass with an 8-mm Dacron prosthesis. The further postoperative course was complicated by thrombotic occlusion of the right brachial artery as the insertion site of the control catheter, and severe posthypoxic encephalopathy, which could be attributed to the long hypoxic duration between the acute type A dissection and initiation of the cardiopulmonary bypass. The patient died on postoperative day 19 due to pneumonia with consecutive multiple organ failure.
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Comment
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In our patient, the retrograde aortic dissection occurred during the intervention and was attributed to the guidewire manipulation and subsequent dilatation and stenting of the false lumen. The guidewire must have been inserted through an entry at the aortic arch into the ascending aorta between layers of the arotic wall. However, the projection of the guidewire over the lumen of the aorta in the angiography controls with usual two-dimensional representation initially inhibited the detection of its incorrect position. The further advance of the stent-graft, together with the guidewire resulted in a re-entry. The subsequent deployment of the stent-graft extended the false lumen, and led to a retrograde type A dissection.
In endovascular stent repair, intravascular ultrasound [6] and transesophageal echocardiography [7] as adjunctive imaging modalities are likely to evaluate the landing zone of stent-graft during the placement. To prevent a retrograde aortic dissection attributed to the guidewire manipulation such as in this case, it is recommendable to perform transesophageal echocardiography or intravascular ultrasound examination even during the introduction of the stiff guidewire to evaluate its real-time position, especially if remarkable kinking in the thoracic aorta is available. Furthermore, it is optimal that intervention of thoracic aneurysm can be performed by a team with a cardiothoracic surgeon with sufficient experience for aortic surgery and in a cardiothoracic operating room with angiography equipment.
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References
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- Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddel RP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms N Eng J Med 1994;331:1729-1734.[Abstract/Free Full Text]
- Neuhauser B, Czermak BV, Fish J, et al. Type A dissection following endovascular thoracic aortic stent-graft repair J Endovasc Ther 2005;12:74-81.[Medline]
- Duda SH, Pusich B, Raygrotzki S, et al. Endovascular implantation of the stent-grafts in the thoracic aorta–mid-term results of a prospective controlled study Fortschr Röntgenstr 2002;174:485-489.
- Lepore V, Lonn L, Delle M, et al. Endograft therapy for diseases of the descending thoracic aorta: results in 43 high-risk patients J Endovasc Ther 2002;9:829-837.[Medline]
- Hansen CJ, Bui H, Donayre CE, et al. Complications of endovascular repair of high-risk and emergent descending thoracic aortic aneurysms and dissections J Vasc Surg 2004;40:228-234.[Medline]
- Koschyk DH, Meinertz T, Hofmann T, et al. Value of intravascular ultrasound for endovascular stent-graft placement in aortic dissection and aneurysm J Card Surg 2003;18:471-477.[Medline]
- Swaminathan M, Lineberger CK, McCann RL, Mathew JP. The importance of intraoperative transesophageal echocardiography in endovascular repair of thoracic aortic aneurysms Anesth Analg 2003;97:1566-1572.[Abstract/Free Full Text]
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Abstract
Introduction
