Ann Thorac Surg 2009;88:e60-e62. doi:10.1016/j.athoracsur.2009.09.083
© 2009 The Society of Thoracic Surgeons
Case Reports
Aortic Dissection Complicating Intraaortic Balloon Pumping: Percutaneous Management of Delayed Spinal Cord Ischemia
Piero Trabattoni, MD,
Stefano Zoli, MD*,
Luca Dainese, MD,
Rita Spirito, MD,
Paolo Biglioli, MD,
Marco Agrifoglio, MD, PhD
Department of Cardiovascular Sciences, University of Milan, Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico, University of Milan, Milan, Italy
Accepted for publication September 24, 2009.
* Address correspondence to Dr Zoli, Department of Cardiovascular Sciences, University of Milan, Centro Cardiologico, Fondazione Monzino IRCCS, Via Parea 4, Milan, 20138, Italy (Email: stefanozoli{at}gmail.com).
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Abstract
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Iatrogenic acute type B dissection is a rare complication of intraaortic balloon pumping. Delayed visceral and spinal cord malperfusion can occur for distal progression of the dissection or relative hypotension. Cerebrospinal fluid drainage and percutaneous balloon fenestration provide a safe and effective method for managing ischemic complications.
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Introduction
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Intraaortic balloon pump (IABP) counterpulsation is the method of first choice for mechanical assistance in patients with cardiogenic shock complicating acute myocardial infarction, and its use is progressively increasing in patients who experience difficult separation from cardiopulmonary bypass (CPB). The benefits of the device are inarguable, but several complications associated with IABP insertion have been reported. Acute aortic dissection with visceral and spinal cord malperfusion is among the most rare and dreaded of the vascular complications.
A 50-year-old hypertensive woman was referred to our institution for unstable angina 7 days after an anterior myocardial infarction treated with thrombolysis. Physical examination was unremarkable. The echocardiogram only showed a slight reduction of the left ventricular ejection fraction (0.50). The coronary angiography demonstrated severe atherosclerotic disease of the left anterior descending artery and of the first obtuse marginal branch of the left circumflex artery.
The patient underwent elective coronary artery bypass grafting on the left anterior descending artery and the first obtuse marginal branch using, respectively, left and right in situ internal thoracic arteries under mild hypothermia and cardioplegic arrest. At weaning from cardiopulmonary bypass, the patient showed important and diffuse heart failure, which made another period of CPB necessary. The two arterial grafts functioned well during this time.
The decision was made to implant an intraaortic balloon pump (IABP) for weaning, and a percutaneous left femoral artery approach was chosen. The introduction of the device was easy and its function was good; nevertheless, an intraoperative transesophageal echocardiogram (TEE) evaluation showed an acute iatrogenic Stanford type B aortic dissection, with the tip of the IABP within the false lumen. The catheter was subsequently removed without immediate complications, and the patient was weaned from CPB with inotropic support. During the intensive care unit stay, cardiac function continued to improve, without any complications related to the aortic dissection.
On postoperative day 3, after a brief period of relative hypotension (mean arterial pressure 60 to 70 mm Hg, with preoperative values of 100 to 110 mm Hg), she suddenly complained of bilateral paresthesia and left leg monoplegia, with an increased value of serum creatinine to 2.6 mg/dL. A computed tomography (CT) scan of the aorta, spinal magnetic resonance imaging (MRI), and neurologic evaluation were obtained. The dissection was now extending from the left subclavian to the infrarenal aorta, with impaired blood flow into the false lumen and the dissection flap prolapsing into the right renal artery with minimal contrast uptake (Fig 1).
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Fig 1. (A) A three-dimensional volume rendering of a computed tomography (CT) scan shows descending aorta dissection and static right renal artery (white arrow) obstruction with asymmetric right renal perfusion. (B) Cross-sectional CT image depicts the descending aorta before fenestration. Note the segmental artery arising from the false lumen with reduced contrast enhancement. (C) Detail of the dissection flap prolapsing into the right renal artery (red arrow) causing complete occlusion of the vessel.
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A cerebrospinal fluid (CSF) catheter was immediately placed. CSF pressure was noted to be high (26 mm Hg), and drainage at a rate of 20 mL/h was initiated, aiming for a pressure of 10 to 12 mm Hg.
The patient was brought to the hybrid suite, vascular access was obtained through the left femoral artery, and right renal stenting with a 6- x 17-mm Radix Carbostent (Sorin Biomedica Cardio SRL, Saluggia, Italy) was performed. Decompression of the false lumen and restoration of adequate spinal cord blood flow was obtained by means of percutaneous balloon fenestration. A 0.035-inch Emerald wire (Cordis Corp, Miami, FL) was advanced trough a Berenstein (Cordis) diagnostic catheter and thrust through the dissection flap. Balloon dilation of the flap with creation of the fenestration tear was performed with an Opta Pro 5- x 40-mm balloon (Cordis).
The patient immediately improved, with resolution of neurologic and renal complications (serum creatinine, 0.80 mg/dL). CSF pressure was monitored for 24 hours and kept within normal limits. The patient was discharged from the hospital without further interventions.
A follow-up CT scan 16 months later showed a widely patent right renal artery stent and regularly sized aorta, with minimal residual dissection of the middescending portion (Fig 2). Electromyography and nerve conduction studies demonstrated bilateral sensitive and motor patterns within normal limits.
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Fig 2. A three-dimensional volume rendering of a thoracoabdominal CT scan at the 16-month follow-up shows minor residual dissection (arrowheads) of the proximal descending aorta. Note the adequate perfusion of the right kidney (bright and symmetric renal contrast enhancement).
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Comment
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Intraaortic balloon pump placement is not free from complications, which have been reported ranging from 8% to 29%, with acute aortic dissection occurring in 1% to 4% [1]. The diagnosis of acute Stanford type B dissection can be made with CT, MRI, and TEE images. The location of the IABP within the false channel usually leads to poor IABP function, but there are reports of an IABP normally functioning from within the false lumen, presumably by transmitting pressure across the intimal flap. Spinal cord complications after type B aortic dissections caused by IABP insertion are very rare [2, 3] and are often associated with severe aortoiliac atherosclerotic disease. If the transfemoral approach is deemed difficult, insertion of the balloon through the ascending aorta should be considered.
Malperfusion syndromes need a prompt diagnosis and quick treatment. Minimally invasive endovascular techniques offer an appealing approach to avoid further interventions in poor surgical candidates. The delayed nature of the spinal cord injury made the diagnosis easy in the present patient because she was conscious; therefore, diagnostic evaluation with CT and MRI scans was quickly performed, and immediate therapeutic acts were undertaken.
Aortic fenestration is a technique to rapidly reverse malperfusion [4, 5]. Creating a hole in the dissection flap allows outflow from the false lumen, which is usually at a higher pressure than the true lumen. The equalization of pressure gradients decompresses the false channel and relieves the obstruction of branch vessels. Surgical fenestration can be achieved through a retroperitoneal approach, thus avoiding a thoracotomy and reducing the surgical effect, but abdominal aortic cross-clamping is still required. Percutaneous fenestration has been reported to be as effective in restoring peripheral blood flow and could be safer in critically ill, hemodynamically unstable patients.
The importance of hemodynamic manipulation, especially in preoperative hypertensive patients, has been highlighted by the Mount Sinai group [6]. In our report, neurologic complications and acute renal failure appeared on postoperative day 3 after a period of moderate hypotension. Several pairs of segmental arteries from T3 to L1 were arising from the false lumen with an already reduced blood flow. We theorize that the relatively low mean arterial pressure in a chronic hypertensive patient might have been the precipitating factor leading to a critically low spinal cord perfusion.
The perioperative role of CSF drainage is well established in thoracic and thoracoabdominal aortic surgery [7]; in addition, it has been reported that CSF drainage may help reverse delayed-onset neurologic deficits [8].
In conclusion, delayed spinal cord ischemia after aortic dissection caused by an IABP is a rare complication that mandates immediate performance of the standard diagnostic procedures and careful management of the arterial pressure. Endovascular balloon fenestration associated with CSF drainage is an attractive technique in critical patients with renal and spinal cord ischemia because of its ability to quickly relieve malperfusion syndrome.
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References
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Abstract
Introduction
