Ann Thorac Surg 2007;83:666-668
© 2007 The Society of Thoracic Surgeons
Case Reports
Combined Open and Endovascular Repair of Acute Type A Aortic Dissection
Vitaly Aleksandrovich Sorokin, MD*,
Chee Fui Chong, MD,
Chuen Neng Lee, MD,
Poo Sing Wong, MD,
Lenny Tan, MD,
Peter Ashley Robless, MD
Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, National University of Singapore, Yong Loo Lin School of Medicine, Singapore
Accepted for publication July 26, 2006.
* Address correspondence to Dr Sorokin, National University Hospital of Singapore, Cardio Thoracic and Vascular Department, 5 Lower Kent Ridge Rd, 119074 Singapore. (Email: vsorokin72{at}hotmail.com).
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Abstract
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A 62-year-old man with an acute Stanford type A dissection underwent successful emergent replacement of the ascending aorta. The patient was readmitted with a left pleural effusion and complex dissection in the arch and descending thoracic aorta. A hybrid surgical procedure was performed involving complete arch transposition, followed by arch and descending aortic stenting, with a good result. The surgical management and techniques are reviewed.
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Introduction
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Persistent or recurrent aortic dissection after successful surgical treatment of acute type A aortic dissection is a well-known complication. Persistence of the false lumen in the arch or descending aorta can result in a fatal complication and has an undesirable impact on long-term prognosis. Endovascular stenting has showed promising results for patients with type B aortic dissection. The role of stenting in management of complex persistent aortic dissection is not well established.
A 62-year-old man with known history of hypertension was admitted with an acute type A ascending aortic dissection extending to the infrarenal abdominal aorta. The patient underwent an emergent replacement of his ascending aorta (interposition method) with a 30-mm tube graft (Vascutek, Renfrewshire, UK) under hypothermic circulatory arrest. He recovered without complication and was discharged 19 days later.
A repeat computed tomography (CT) scan showed new development of a complex dissection in the arch and descending thoracic aorta, with a large false lumen compressing on the true lumen. There was also a left pleural effusion with signs of contrast leak that indicated a possible contained rupture and an associated drop in hemoglobin (10.6 to 8.6 g/dL). Transesophageal echocardiography showed a well-defined connection between a perfused false lumen and the true lumen of the descending aorta.
The patient underwent supraaortic transposition with endovascular stenting of the arch and descending thoracic aorta. A hybrid procedure was performed through a redo median sternotomy. A bypass from the ascending aortic to innominate and left common carotid arteries was created using a 14-mm x 7-mm Y limb tapering graft conduit from the previously replaced interposition aortic graft to both the innominate and left common carotid arteries (Vascutek). The origins of all three supraaortic vessels (innominate, left common carotid, left subclavian arteries) were ligated to prevent endoleak.
Two 44-mm x 134-mm Zenith TX2 (Cook, Bloomington, MN) thoracic stent grafts were deployed. The first was introduced through the right femoral artery over a 0.035-mm Lunderquist guidewire (Cook, Bloomington, MN) and deployed so that it overlapped the distal border of the previously replaced ascending aorta. The second stent graft was deployed within the distal end of the first graft and extending across the whole arch of aorta to the descending thoracic aorta just above T10 thoracic vertebra. Balloon molding of proximal graft and overlapping segment were performed. Intraoperative transesophageal echocardiography confirmed exclusion of the false lumen.
A left hemothorax was treated with closed intercostal drainage. Repeat CT scans of the thorax and abdomen on postoperative day 12 confirmed good filling of the neck vessels through the supra aortic transposition graft, no evidence of endoleak in the region of the stent graft, and a reduction in the size of the false lumen.
The patient recovered well, without significant ischemic or neurologic complications, and was discharged on postoperative day 16. A repeat CT scan of the thorax 1 year later showed that the endograft was adequately positioned in the aortic arch and descending aorta, and no endoleak was evident (Fig 1). The false lumen was completely obliterated.
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Fig 1. A three-dimensional (3D) reconstructed image of a computed tomography study done 1 year after complete arch transposition with Y-graft (arrow) and stenting. (Courtesy of Dr Luis Serra, Volume Interaction Pte, Ltd.)
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Comment
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Open surgery has traditionally been performed for acute type A aortic dissection, with a mortality rate of 10% to 20% [1, 2]. Surgical treatment for Stanford type A dissection can prevent fatal complications such as cardiac tamponade, myocardial infarction, heart failure, and aortic rupture, and can significantly decrease early mortality [1–3]. Late results have been disappointing, even after an initial successful operation [2, 3]. Surgical repair is limited to the ascending aorta in most cases. The distal aortic dissection that was not primarily replaced is thought to be responsible for the considerable number of postoperative complications and deaths [1]. Persistent aortic dissection and recurrent dissection are well known early and late postoperative complications [1, 2, 4]. The problem of persistent distal false perfusion lumen has been found in 50% to 100% of patients with ascending aorta replacement [1]. Ergin and colleagues [5] showed better long-term survival for patients with thrombosed false lumen after primary aortic repair.
According to Borst and colleagues [1], the redissection rate for patients with surgically treated proximal dissection was up to 35%. Complications of persistent dissection and newly developed dissection of distal aorta are often fatal. DeBakey and colleague [6], in their very large series, showed that most deaths after surgical treatment for aortic dissection were due to rupture of the aorta.
Surgical treatment is advocated for patients with persistent false lumen and development life-threatening complication [1]. Morbidity and mortality rates for reoperation on the dissected aorta are higher compared with primary surgery and may be increased to 25% with arch involvement [1]. Intraluminal stenting of dissecting aorta, a recent development, shows promising results for patients with type B aortic dissection [4, 7, 8]. Stenting of the dissected arch has not been studied extensively in the context of complex treatment for type A dissection [3, 8].
In our case, the patient was readmitted to the hospital with complex dissection in the arch and descending thoracic aorta 3 weeks after primary repair of the ascending aorta. Repeat CT scan of the thorax showed a large expanding false lumen compressing on the true lumen and newly developed left pleural effusion. The pleural effusion, combined with signs of contrast extravasation and the drop in hemoglobin, were crucial factors in the decision to operate.
To avoid complex redo open surgery requiring circulatory arrest with high mortality and morbidity, we performed endovascular stenting of the dissected arch and descending aorta with supraaortic transposition. Endovascular stenting of the dissected aortic arch was possible only after transposition of innominate and left common carotid arteries. This technique has been described previously [8]. One possible complication of arch stenting is persistent endoleak due to supraaortic branches [7]. Two stents were used to completely cover the arch and descending aorta down to the T10 thoracic vertebra. A postoperative CT thorax scan on postoperative day 12 confirmed the successful occlusion of the false lumen without endoleak. Our patient remained well at the 12-month follow-up.
This case demonstrates that close follow-up is very important to diagnose early, life-threatening complications of acute type A aortic dissection. Hybrid procedures can be a useful option for patients with successfully treated proximal dissection but with persistent or newly developed dissection of distal aorta. We believe this procedure can minimize mortality and morbidity for select group of patient with complex aortic dissection.
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References
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- Borst HG, Heinemann MK, Stone CD. Surgical treatment of aortic dissection. New York: Churchill Livingstone; 1996. pp. 357.
- Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB. Kirklin/Barratt-Boyes Cardiac Surgery. 3rd ed.. Salt Lake City: Churchill Livingstone; 2003. pp. 1938.
- Fleck T, Hutschala D, Czerny M, et al. Combined surgical and endovascular treatment of acute aortic dissection type A: preliminary results Ann Thorac Surg 2002;74:761-766.[Abstract/Free Full Text]
- Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management Circulation 2003;108:772-778.[Free Full Text]
- Ergin MA, Phillips RA, Galla JD, et al. Significance of distal false lumen after type A dissection repair Ann Thorac Surg 1994;57:820-826.[Abstract]
- DeBakey ME, McCollum CH, Crawford ES, et al. Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically Surgery 1982;92:1118-1134.[Medline]
- Shigemura N, Kato M, Kuratani T, Funakoshi Y, Kaneko M. New operative method for acute type b dissection: left carotid artery-left subclavian artery bypass combined with endovascular stent-graft implantation J Thorac Cardiovasc Surg 2000;120:406-408.[Free Full Text]
- Bergeron P, Coulon P, De Chaumaray T, et al. Great vessels transposition and aortic arch exclusion J Cardiovasc Surg 2005;46:141-147.[Medline]
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Abstract
Introduction
