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Case Study
Endovascular repair for retrograde type A aortic dissection with malperfusion
Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314548230 aan.sagepub.com
Shinya Takahashi, Keijiro Katayama, Taiichi Takasaki and Taijiro Sueda
Abstract An 81-year-old man became semiconscious and suffered back pain followed by chest pain. Computed tomography showed retrograde acute type A aortic dissection with entries in the proximal and middle descending aorta, and an occluded true lumen of the right carotid artery. Emergency endovascular repair was performed. Immediately after deploying a stent-graft, aortography showed recanalization of the right carotid artery and no blood flow in the false lumen of the ascending aorta and aortic arch. The postoperative course was uneventful. Computed tomography at 6 months after the procedure showed obliteration of the false lumen and a patent right carotid artery.
Keywords Aged, 80 and over, Aneurysm, dissecting, Aortic aneurysm, thoracic, Blood vessel prosthesis implantation, Carotid arteries, Endovascular procedures
Introduction Stanford type A acute aortic dissection remains a lifethreatening disease, but favorable results of endovascular repair, especially in retrograde type A dissection, have been reported recently. We described the successful endovascular repair of retrograde type A acute aortic dissection with neck vessel malperfusion, which was a rare because antegrade flow in the true lumen of the brachiocephalic artery usually spreads it against the dilated false lumen with lower pressure.
Case report A 81-year-old man became semiconscious and noticed sudden back pain. The next day, he had chest pain and neck pain on the right side, and on the 3rd day after the onset of back pain, he was admitted to our hospital. The right and left brachial arterial pressures were different: 150/90 and 180/100 mm Hg, respectively. Enhanced computed tomography revealed retrograde Stanford type A aortic dissection extending from just above the sinotubular junction to the abdominal aortic bifurcation, and the proximal ascending aorta was thrombosed (Figure 1). There were two major intimal tears at 2 cm distal to the origin of the left subclavian
artery and at the Th6 level of the descending aorta. The celiac artery communicated with the false lumen. The true lumen of the brachiocephalic artery and right carotid artery were occluded by the thrombosed false lumen. The diameters of the ascending and middle descending aorta were 46.1 and 34.3 mm, respectively. Because surgical repair of Stanford type A dissection with closure of the entries in the descending aorta was considered too invasive for an octogenarian, endovascular aortic repair was planned. Under general anesthesia, an endovascular procedure was performed through a bilateral femoral approach. Aortography showed brachiocephalic artery occlusion and false lumen enhancement starting from the distal arch and flowing towards the ascending and distal descending aorta (Figure 2A). The left common carotid artery and the left subclavian artery were intact. Two stent-grafts of 31 100 mm Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan Corresponding author: Shinya Takahashi, MD, PhD, Department of Cardiovascular Surgery, Hiroshima University Hospital, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan. Email: [email protected]
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Figure 1. (A, B, C) Preoperative computed tomography showing retrograde type A aortic dissection, a compressed ascending aorta, occlusion of the brachiocephalic and right carotid arteries, and an enhanced false lumen of the distal arch and descending aorta. The right subclavian artery was enhanced through the vertebral artery.
Figure 2. Digital subtraction angiography showing (A) the intimal entry tear on the proximal descending aorta (black arrow) and the occluded brachiocephalic artery before deploying a stent-graft, and (B) closure of the intimal tear with the stent-graft and the recanalized brachiocephalic artery (black arrows).
(Gore TAG, WL Gore, Flagstaff, AZ, USA) were placed from the distal side of the left subclavian artery to below Th6 level, without touching. Subsequent aortography showed closure of the intimal tear in the distal aorta, restoration of the brachiocephalic artery and right common carotid artery, and no intimal tear in the descending thoracic aorta (Figure 2B). Blood flow was detected in the true lumen of the right carotid artery by percutaneous ultrasonography. Computed tomography on the 5th postprocedure day showed a diminishing ascending aortic false lumen (Figure 3A, 3B). The patient had no
neurological deficit and was uneventfully discharged on the 14th day after admission. Six months after the procedure, computed tomography showed obliteration of the false lumen of the thrombosed ascending aorta and intact neck branching arteries; the diameters of the ascending and middle descending aorta decreased to 41.9 and 33.9 mm (Figure 3C).
Discussion For surgical treatment of retrograde acute type A aortic dissection, replacement of the ascending aorta, with or
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Figure 3. (A, B) Post-procedure computed tomography on the 5th day, and (C) the 6th month, showing that the false lumen had been obliterated by the endovascular stent-graft, the brachiocephalic artery and right carotid artery were patent, and the true lumen of the ascending aorta was restored.
without hemiarch or total arch replacement, is usually performed. However, these techniques do not eliminate flow in the false lumen, which correlates with several late complications including aneurysm dilatation of the distal aorta, reoperation, and rupture. Extensive replacement of the thoracic aorta achieves successful one-stage repair, but the operative mortality ranges from 13% to 46%.1 Endovascular repair for acute type A aortic dissection was first described in 1998 and performed in selected patients with retrograde type A aortic dissection.2 In most cases, entry closure of the descending aorta was performed. However, in cases where the primary entry was around a neck vessel, entry closure with supraaortic transposition between the left subclavian artery and the left or right subclavian artery was carried out. The hospital mortality rate of endovascular repair is 0% to 3.6%, and there have been a few procedurerelated complications including stroke.2,3 Theoretically, this procedure carries a possible risk of spinal cord ischemia which might occur after placement of a stent-graft on the descending aorta in type B dissection. Additional procedures have been required in some cases. Kusagawa and colleagues3 reported that an additional stent-graft was placed for a newly developed intimal tear at the initial stent, and additional surgery was performed because of a patent false lumen in the ascending aorta due to an initial tear thought to be a reentry in the cervical branch. They also reported that treatment failure requiring an additional procedure was
observed in 20% of acute type A retrograde dissections treated by endovascular stent-grafts. There are two malperfusion patterns of branch vessels: static and dynamic.4 In the present case, the static mechanisms allowed the narrowed brachiocephalic artery and entry closure in the acute phase to recover brachiocephalic artery flow with the decompressed false lumen. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Kaji S, Akasaka T, Katayama M, et al. Prognosis of retrograde dissection from the descending to the ascending aorta. Circulation 2003; 108(Suppl II): 300–306. 2. Lyons O, Clough R, Patel A, Saha P, Carrell T and Taylor P. Endovascular management of Stanford type a dissection or intramural hematoma with a distal primary entry tear. J Endovasc Ther 2011; 18: 591–600. 3. Kusagawa H, Shimono T, Ishida M, et al. Changes in false lumen after transluminal stent-graft placement in aortic dissections: six years’ experience. Circulation 2005; 111: 2951–2957. 4. Williams DM, Lee DY, Hamilton BH, et al. The dissected aorta. part III. Anatomy and radiologic diagnosis of branch-vessel compromise. Radiology 1997; 203: 37–44.
Downloaded from aan.sagepub.com at PENNSYLVANIA STATE UNIV on November 16, 2015
(AAN)
[1–3] [PREPRINTER stage]
Case Study
Endovascular repair for retrograde type A aortic dissection with malperfusion
Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314548230 aan.sagepub.com
Shinya Takahashi, Keijiro Katayama, Taiichi Takasaki and Taijiro Sueda
Abstract An 81-year-old man became semiconscious and suffered back pain followed by chest pain. Computed tomography showed retrograde acute type A aortic dissection with entries in the proximal and middle descending aorta, and an occluded true lumen of the right carotid artery. Emergency endovascular repair was performed. Immediately after deploying a stent-graft, aortography showed recanalization of the right carotid artery and no blood flow in the false lumen of the ascending aorta and aortic arch. The postoperative course was uneventful. Computed tomography at 6 months after the procedure showed obliteration of the false lumen and a patent right carotid artery.
Keywords Aged, 80 and over, Aneurysm, dissecting, Aortic aneurysm, thoracic, Blood vessel prosthesis implantation, Carotid arteries, Endovascular procedures
Introduction Stanford type A acute aortic dissection remains a lifethreatening disease, but favorable results of endovascular repair, especially in retrograde type A dissection, have been reported recently. We described the successful endovascular repair of retrograde type A acute aortic dissection with neck vessel malperfusion, which was a rare because antegrade flow in the true lumen of the brachiocephalic artery usually spreads it against the dilated false lumen with lower pressure.
Case report A 81-year-old man became semiconscious and noticed sudden back pain. The next day, he had chest pain and neck pain on the right side, and on the 3rd day after the onset of back pain, he was admitted to our hospital. The right and left brachial arterial pressures were different: 150/90 and 180/100 mm Hg, respectively. Enhanced computed tomography revealed retrograde Stanford type A aortic dissection extending from just above the sinotubular junction to the abdominal aortic bifurcation, and the proximal ascending aorta was thrombosed (Figure 1). There were two major intimal tears at 2 cm distal to the origin of the left subclavian
artery and at the Th6 level of the descending aorta. The celiac artery communicated with the false lumen. The true lumen of the brachiocephalic artery and right carotid artery were occluded by the thrombosed false lumen. The diameters of the ascending and middle descending aorta were 46.1 and 34.3 mm, respectively. Because surgical repair of Stanford type A dissection with closure of the entries in the descending aorta was considered too invasive for an octogenarian, endovascular aortic repair was planned. Under general anesthesia, an endovascular procedure was performed through a bilateral femoral approach. Aortography showed brachiocephalic artery occlusion and false lumen enhancement starting from the distal arch and flowing towards the ascending and distal descending aorta (Figure 2A). The left common carotid artery and the left subclavian artery were intact. Two stent-grafts of 31 100 mm Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan Corresponding author: Shinya Takahashi, MD, PhD, Department of Cardiovascular Surgery, Hiroshima University Hospital, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan. Email: [email protected]
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Figure 1. (A, B, C) Preoperative computed tomography showing retrograde type A aortic dissection, a compressed ascending aorta, occlusion of the brachiocephalic and right carotid arteries, and an enhanced false lumen of the distal arch and descending aorta. The right subclavian artery was enhanced through the vertebral artery.
Figure 2. Digital subtraction angiography showing (A) the intimal entry tear on the proximal descending aorta (black arrow) and the occluded brachiocephalic artery before deploying a stent-graft, and (B) closure of the intimal tear with the stent-graft and the recanalized brachiocephalic artery (black arrows).
(Gore TAG, WL Gore, Flagstaff, AZ, USA) were placed from the distal side of the left subclavian artery to below Th6 level, without touching. Subsequent aortography showed closure of the intimal tear in the distal aorta, restoration of the brachiocephalic artery and right common carotid artery, and no intimal tear in the descending thoracic aorta (Figure 2B). Blood flow was detected in the true lumen of the right carotid artery by percutaneous ultrasonography. Computed tomography on the 5th postprocedure day showed a diminishing ascending aortic false lumen (Figure 3A, 3B). The patient had no
neurological deficit and was uneventfully discharged on the 14th day after admission. Six months after the procedure, computed tomography showed obliteration of the false lumen of the thrombosed ascending aorta and intact neck branching arteries; the diameters of the ascending and middle descending aorta decreased to 41.9 and 33.9 mm (Figure 3C).
Discussion For surgical treatment of retrograde acute type A aortic dissection, replacement of the ascending aorta, with or
Downloaded from aan.sagepub.com at PENNSYLVANIA STATE UNIV on November 16, 2015
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Figure 3. (A, B) Post-procedure computed tomography on the 5th day, and (C) the 6th month, showing that the false lumen had been obliterated by the endovascular stent-graft, the brachiocephalic artery and right carotid artery were patent, and the true lumen of the ascending aorta was restored.
without hemiarch or total arch replacement, is usually performed. However, these techniques do not eliminate flow in the false lumen, which correlates with several late complications including aneurysm dilatation of the distal aorta, reoperation, and rupture. Extensive replacement of the thoracic aorta achieves successful one-stage repair, but the operative mortality ranges from 13% to 46%.1 Endovascular repair for acute type A aortic dissection was first described in 1998 and performed in selected patients with retrograde type A aortic dissection.2 In most cases, entry closure of the descending aorta was performed. However, in cases where the primary entry was around a neck vessel, entry closure with supraaortic transposition between the left subclavian artery and the left or right subclavian artery was carried out. The hospital mortality rate of endovascular repair is 0% to 3.6%, and there have been a few procedurerelated complications including stroke.2,3 Theoretically, this procedure carries a possible risk of spinal cord ischemia which might occur after placement of a stent-graft on the descending aorta in type B dissection. Additional procedures have been required in some cases. Kusagawa and colleagues3 reported that an additional stent-graft was placed for a newly developed intimal tear at the initial stent, and additional surgery was performed because of a patent false lumen in the ascending aorta due to an initial tear thought to be a reentry in the cervical branch. They also reported that treatment failure requiring an additional procedure was
observed in 20% of acute type A retrograde dissections treated by endovascular stent-grafts. There are two malperfusion patterns of branch vessels: static and dynamic.4 In the present case, the static mechanisms allowed the narrowed brachiocephalic artery and entry closure in the acute phase to recover brachiocephalic artery flow with the decompressed false lumen. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Kaji S, Akasaka T, Katayama M, et al. Prognosis of retrograde dissection from the descending to the ascending aorta. Circulation 2003; 108(Suppl II): 300–306. 2. Lyons O, Clough R, Patel A, Saha P, Carrell T and Taylor P. Endovascular management of Stanford type a dissection or intramural hematoma with a distal primary entry tear. J Endovasc Ther 2011; 18: 591–600. 3. Kusagawa H, Shimono T, Ishida M, et al. Changes in false lumen after transluminal stent-graft placement in aortic dissections: six years’ experience. Circulation 2005; 111: 2951–2957. 4. Williams DM, Lee DY, Hamilton BH, et al. The dissected aorta. part III. Anatomy and radiologic diagnosis of branch-vessel compromise. Radiology 1997; 203: 37–44.
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