International Journal of Cardiology 176 (2014) e70–e72
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Atrial septal defect occluder for the distal re-entry tear in type B aortic dissection Jia Hu, Jian Yang ⁎ Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
a r t i c l e
i n f o
Article history: Received 1 June 2014 Accepted 26 July 2014 Available online 2 August 2014 Keywords: Type B aortic dissection Re-entry tear Atrial septal defect occluder
Thoracic endovascular aortic repair (TEVAR) has recently been proposed as a preferable strategy for patients with type B aortic dissection (TB-AD) complicated by malperfusion, rupture or rapid expansion in the distal arch or proximal descending aorta [1,2]. However, such patients with unsealed distal re-entries have poor outcomes because of incomplete false lumen (FL) thrombosis and pseudo-aneurysmal dilatation due to unlimited retrograde flow [1–5]. This clinical scenario requires novel approaches to achieve complete exclusion of the FL with coverage of any associated re-entry. A 60-year old man who had a history of hypertension and chronic obstructive pulmonary disease was referred to our unit because of sudden onset of chest and back pain. His computed tomographic angiography (CTA) confirmed an acute type B aortic dissection. The primary entry tears between the true and the false lumens were in the proximal descending aorta, while the re-entry site connecting with an enlarged pseudo-aneurysmatic sac was adjacent to the celiac ostium (Fig. 1A). The dissection was uncomplicated and was managed with intensive medical therapy initially. However, because of persistent back pain, enlargement of the FL and the anatomic particularity of the re-entry tear (Fig. 1B), we scheduled endovascular coverage of the entry tear combined with transcatheter closure of the re-entry using an atrial septal defect (ASD) occluder for complete exclusion of the FL. The informed consent was signed by the patient and his family members after being given detailed explanation of risks and benefits of TEVAR and off-label use of the ASD occluder in TB-AD. ⁎ Corresponding author. Tel./fax: +86 28 85421833. E-mail address: [email protected] (J. Yang).
http://dx.doi.org/10.1016/j.ijcard.2014.07.160 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
After obtaining left common femoral arterial access, a stent-graft (32 × 200 mm, Medtronic Cardiovascular, Santa Rosa, CA, USA) was deployed at the proximal segment of the descending aorta with the aid of ultra stiff guide wire. Sealing of the primary entry tear was satisfactory at completion angiography. A 5-F sheath, 0.035 super-slip guide wire, and 5-F pigtail catheter were advanced into the descending aorta through the right femoral artery. The pigtail catheter was exchanged for a 4-F Cobra catheter, and a 9-F long FuStar Steerable sheath (Lifetech Scientific Co. Ltd., Shenzhen, China) was then navigated over the wire to the FL through the re-entry tear. Sized to exceed the 8-mmdiameter re-entry tear by 6 mm, a 14 mm double-disc ASD occluder (SHSMA Co., Ltd., Shanghai, China) (Fig. 2A) was advanced into the long sheath then the FL through the re-entry tear. Under fluoroscopic guidance, the anterior disc of the occluder was deployed in the FL and pulled back gently against the rim of the dissection flap. Further withdrawal of the sheath was made to release the waist of the device cross the tear and then the posterior disc in the true lumen. Angiography on completion of the surgery revealed no leakage into the FL from the associated tears (Fig. 2B). The patient tolerated this procedure well and recovered uneventfully. The 2-week CTA demonstrated ideal positioning of the occluder (Fig. 2C) with complete thrombosis of the FL (Fig. 2D). The established treatment for complicated acute TB-AD is to seal the proximal entry tear and prevent antegrade flow into the FL by using aortic stent-graft. However, the benefits of this endovascular treatment could be limited by uncovered re-entry tears, through which retrograde flow may lead to incomplete thrombogenic environment in the FL and adversely influence aortic remodeling. Therefore, complete exclusion of the FL with re-entry coverage is required, particularly in this patient who had a large re-entry tear, which was unlikely to seal spontaneously after TEVAR, and the risk of pseudo-aneurysmal dilatation and even rupture due to unlimited retrograde flow would persist. Although the treatment of the re-entry tear is indicated in this case, it is unfavorable for exclusion with a stent-graft unless the adjacent celiac ostium is covered, which could result in ischemia of the visceral organs. Surgical revascularization prior to TEVAR may provide a chance for complete exclusion of the FL without irreversible sacrifice of the branch vessels covered by the stent, however, this strategy may expose patient to a high risk of morbidity and mortality [1,2]. Obliterating the large reentry tear with an ASD occluder seems logically and technically feasible, since the anatomical configuration of the re-entry site in this case is similar to an ASD, which is somewhat a gap in a thin-walled structure with two large chambers on each side [6].
J. Hu, J. Yang / International Journal of Cardiology 176 (2014) e70–e72
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Fig. 1. (A) Preoperative CT demonstrating an aneurysmal type B dissection with large entry and re-entry tears; (B) the distal re-entry tear located adjacent to the celiac ostium.
The attractive advantages of the use of an occluder in this patient are avoiding coverage of the celiac ostium and eliminating the risk of paraplegia with significantly shorter aortic coverage. Furthermore, we applied the ASD occluder device to take advantage of its unequal-sized discs, with the smaller one, positioned inside the aorta, which might be less likely interfering with the adjacent branch vessels. Another concern on this technique is whether to schedule the treatment of distal reentry before or after the proximal entry coverage of aortic stent-graft. In contrast to previous reports by others [7,8], we chose to deploy the occluder retrogradely via the true lumen after TEVAR. Because there is a potentially increased risk of occluder migration and pseudoaneurysmal pressurization and even rupture shortly after sealing of the distal outlet of the FL without limiting antegrade flow through the patent entry tear by TEVAR. In conclusion, we believe that the combining use of a selected occluder for re-entry tear and TEVAR for the entry coverage is a technically feasible, safe and effective strategy for selected patients with TBAD. However, long-term follow-up is required to better establish the efficacy and durability of this transcatheter approach. Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
Acknowledgments This work was supported in part by the National Natural Science Foundation of China (No. 81300155). References [1] Fattori R, Cao P, De Rango P, et al. Interdisciplinary expert consensus document on management of type B aortic dissection. J Am Coll Cardiol 2013;61:1661–78. [2] Pacini D, Di Marco L, Fortuna D, et al. Acute aortic dissection: epidemiology and outcomes. Int J Cardiol 2013;167:2806–12. [3] Qin YL, Deng G, Li TX, Wang W, Teng GJ. Treatment of acute type-B aortic dissection: thoracic endovascular aortic repair or medical management alone? JACC Cardiovasc Interv 2013;6:185–91. [4] Tsai TT, Evangelista A, Nienaber CA, et al. Partial thrombosis of the false lumen in patients with acute type B aortic dissections. N Engl J Med 2007;357:349–59. [5] Nienaber CA, Rousseau H, Eggebrecht H, et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation 2009;120:2519–28. [6] Tao KY, An Q, Gan CP, Tang H, Feng Y, Song HB. Give the patient another chance: peratrial device closure of a secundum atrial septal defect that failed percutaneous device closure. J Thorac Cardiovasc Surg 2009;137:1024–7. [7] Katayama K, Uchida N, Takahashi S, Sueda T. Scheduled re-entry coil embolization before entry coverage of thoracic endovascular stent grafting for aneurysmal chronic type B aortic dissection. Interact Cardiovasc Thorac Surg 2012;15:800–1. [8] Tang X, Fu W, Xu X, et al. Use of a vascular occluder to treat a re-entry tear in a patient with stanford type B aortic dissection: acute and 1-year results. J Endovasc Ther 2008; 15:566–9.
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J. Hu, J. Yang / International Journal of Cardiology 176 (2014) e70–e72
Fig. 2. (A) Atrial septal defect (ASD) occluder used for transcatheter closure of the re-entry tear; (B) complete exclusion of the false lumen with no compromised perfusion of adjacent branch vessels; (C) two-week postoperative CT demonstrating satisfactory position of the occluder and (D) complete thrombosis of the false lumen. SMA, superior mesenteric artery.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Atrial septal defect occluder for the distal re-entry tear in type B aortic dissection Jia Hu, Jian Yang ⁎ Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
a r t i c l e
i n f o
Article history: Received 1 June 2014 Accepted 26 July 2014 Available online 2 August 2014 Keywords: Type B aortic dissection Re-entry tear Atrial septal defect occluder
Thoracic endovascular aortic repair (TEVAR) has recently been proposed as a preferable strategy for patients with type B aortic dissection (TB-AD) complicated by malperfusion, rupture or rapid expansion in the distal arch or proximal descending aorta [1,2]. However, such patients with unsealed distal re-entries have poor outcomes because of incomplete false lumen (FL) thrombosis and pseudo-aneurysmal dilatation due to unlimited retrograde flow [1–5]. This clinical scenario requires novel approaches to achieve complete exclusion of the FL with coverage of any associated re-entry. A 60-year old man who had a history of hypertension and chronic obstructive pulmonary disease was referred to our unit because of sudden onset of chest and back pain. His computed tomographic angiography (CTA) confirmed an acute type B aortic dissection. The primary entry tears between the true and the false lumens were in the proximal descending aorta, while the re-entry site connecting with an enlarged pseudo-aneurysmatic sac was adjacent to the celiac ostium (Fig. 1A). The dissection was uncomplicated and was managed with intensive medical therapy initially. However, because of persistent back pain, enlargement of the FL and the anatomic particularity of the re-entry tear (Fig. 1B), we scheduled endovascular coverage of the entry tear combined with transcatheter closure of the re-entry using an atrial septal defect (ASD) occluder for complete exclusion of the FL. The informed consent was signed by the patient and his family members after being given detailed explanation of risks and benefits of TEVAR and off-label use of the ASD occluder in TB-AD. ⁎ Corresponding author. Tel./fax: +86 28 85421833. E-mail address: [email protected] (J. Yang).
http://dx.doi.org/10.1016/j.ijcard.2014.07.160 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
After obtaining left common femoral arterial access, a stent-graft (32 × 200 mm, Medtronic Cardiovascular, Santa Rosa, CA, USA) was deployed at the proximal segment of the descending aorta with the aid of ultra stiff guide wire. Sealing of the primary entry tear was satisfactory at completion angiography. A 5-F sheath, 0.035 super-slip guide wire, and 5-F pigtail catheter were advanced into the descending aorta through the right femoral artery. The pigtail catheter was exchanged for a 4-F Cobra catheter, and a 9-F long FuStar Steerable sheath (Lifetech Scientific Co. Ltd., Shenzhen, China) was then navigated over the wire to the FL through the re-entry tear. Sized to exceed the 8-mmdiameter re-entry tear by 6 mm, a 14 mm double-disc ASD occluder (SHSMA Co., Ltd., Shanghai, China) (Fig. 2A) was advanced into the long sheath then the FL through the re-entry tear. Under fluoroscopic guidance, the anterior disc of the occluder was deployed in the FL and pulled back gently against the rim of the dissection flap. Further withdrawal of the sheath was made to release the waist of the device cross the tear and then the posterior disc in the true lumen. Angiography on completion of the surgery revealed no leakage into the FL from the associated tears (Fig. 2B). The patient tolerated this procedure well and recovered uneventfully. The 2-week CTA demonstrated ideal positioning of the occluder (Fig. 2C) with complete thrombosis of the FL (Fig. 2D). The established treatment for complicated acute TB-AD is to seal the proximal entry tear and prevent antegrade flow into the FL by using aortic stent-graft. However, the benefits of this endovascular treatment could be limited by uncovered re-entry tears, through which retrograde flow may lead to incomplete thrombogenic environment in the FL and adversely influence aortic remodeling. Therefore, complete exclusion of the FL with re-entry coverage is required, particularly in this patient who had a large re-entry tear, which was unlikely to seal spontaneously after TEVAR, and the risk of pseudo-aneurysmal dilatation and even rupture due to unlimited retrograde flow would persist. Although the treatment of the re-entry tear is indicated in this case, it is unfavorable for exclusion with a stent-graft unless the adjacent celiac ostium is covered, which could result in ischemia of the visceral organs. Surgical revascularization prior to TEVAR may provide a chance for complete exclusion of the FL without irreversible sacrifice of the branch vessels covered by the stent, however, this strategy may expose patient to a high risk of morbidity and mortality [1,2]. Obliterating the large reentry tear with an ASD occluder seems logically and technically feasible, since the anatomical configuration of the re-entry site in this case is similar to an ASD, which is somewhat a gap in a thin-walled structure with two large chambers on each side [6].
J. Hu, J. Yang / International Journal of Cardiology 176 (2014) e70–e72
e71
Fig. 1. (A) Preoperative CT demonstrating an aneurysmal type B dissection with large entry and re-entry tears; (B) the distal re-entry tear located adjacent to the celiac ostium.
The attractive advantages of the use of an occluder in this patient are avoiding coverage of the celiac ostium and eliminating the risk of paraplegia with significantly shorter aortic coverage. Furthermore, we applied the ASD occluder device to take advantage of its unequal-sized discs, with the smaller one, positioned inside the aorta, which might be less likely interfering with the adjacent branch vessels. Another concern on this technique is whether to schedule the treatment of distal reentry before or after the proximal entry coverage of aortic stent-graft. In contrast to previous reports by others [7,8], we chose to deploy the occluder retrogradely via the true lumen after TEVAR. Because there is a potentially increased risk of occluder migration and pseudoaneurysmal pressurization and even rupture shortly after sealing of the distal outlet of the FL without limiting antegrade flow through the patent entry tear by TEVAR. In conclusion, we believe that the combining use of a selected occluder for re-entry tear and TEVAR for the entry coverage is a technically feasible, safe and effective strategy for selected patients with TBAD. However, long-term follow-up is required to better establish the efficacy and durability of this transcatheter approach. Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
Acknowledgments This work was supported in part by the National Natural Science Foundation of China (No. 81300155). References [1] Fattori R, Cao P, De Rango P, et al. Interdisciplinary expert consensus document on management of type B aortic dissection. J Am Coll Cardiol 2013;61:1661–78. [2] Pacini D, Di Marco L, Fortuna D, et al. Acute aortic dissection: epidemiology and outcomes. Int J Cardiol 2013;167:2806–12. [3] Qin YL, Deng G, Li TX, Wang W, Teng GJ. Treatment of acute type-B aortic dissection: thoracic endovascular aortic repair or medical management alone? JACC Cardiovasc Interv 2013;6:185–91. [4] Tsai TT, Evangelista A, Nienaber CA, et al. Partial thrombosis of the false lumen in patients with acute type B aortic dissections. N Engl J Med 2007;357:349–59. [5] Nienaber CA, Rousseau H, Eggebrecht H, et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation 2009;120:2519–28. [6] Tao KY, An Q, Gan CP, Tang H, Feng Y, Song HB. Give the patient another chance: peratrial device closure of a secundum atrial septal defect that failed percutaneous device closure. J Thorac Cardiovasc Surg 2009;137:1024–7. [7] Katayama K, Uchida N, Takahashi S, Sueda T. Scheduled re-entry coil embolization before entry coverage of thoracic endovascular stent grafting for aneurysmal chronic type B aortic dissection. Interact Cardiovasc Thorac Surg 2012;15:800–1. [8] Tang X, Fu W, Xu X, et al. Use of a vascular occluder to treat a re-entry tear in a patient with stanford type B aortic dissection: acute and 1-year results. J Endovasc Ther 2008; 15:566–9.
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J. Hu, J. Yang / International Journal of Cardiology 176 (2014) e70–e72
Fig. 2. (A) Atrial septal defect (ASD) occluder used for transcatheter closure of the re-entry tear; (B) complete exclusion of the false lumen with no compromised perfusion of adjacent branch vessels; (C) two-week postoperative CT demonstrating satisfactory position of the occluder and (D) complete thrombosis of the false lumen. SMA, superior mesenteric artery.
