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CASE REPORT KUMPATI ET AL ENDOVASCULAR REPAIR OF ASCENDING AORTA

Ann Thorac Surg 2014;97:700–3

Fig 3. Transesophageal echocardiogram during (A) systole and (B) diastole showing ascending aorta, aortic valve and proximal intimal flap. (Av ¼ aortic valve; F ¼ proximal intimal flap.)

FEATURE ARTICLES

in the diagnosis of aortic dissection, but it was not accurate enough to differentiate it from a penetrating atherosclerotic ulcer, which would have different clinical implications as one of the variants of aortic dissection [5]. As has been reported previously [2], our findings in CT were not conclusive for aortic dissection because the scan lacked the demonstration of true and false lumens separated by an intimal flap. Logically, this was related to the short aortic segment involved in the dissection process. We found it to be in the best interest of the patient to define the aortic pathologic condition before going into the operating room, and therefore performed the TEE preoperatively. Inasmuch as the aortic valve was anatomically normal, one can intuitively argue whether a supracoronary ascending aortic replacement or a valve-sparing ascending aortic replacement could have, or should have, been performed. We believe that because the aortic circle around the coronary ostia was extensively involved in the dissection process, a supracoronary ascending aortic replacement would have been a less than satisfactory procedure in that regard. Instead, we preferred to separate both coronary buttons from their Valsalva sinuses surgically, then fix the surrounding dissected layers using 4-0 Prolene and a strip of Teflon while sewing them back to a firm tissue such as a Dacron graft. Obviously, that decision does not prevent one from performing a valvesparing procedure, which any team highly experienced in these procedures might have considered in such an emergency situation.

References 1. Yavuz S, Elhan K, Eris C, Tugrul Goncu M. Intimo-intimal intussusception: a rare clinical form of aortic dissection. Eur J Cardiothorac Surg 2003;23:850–1. _ 2. Yamabi H, Imanaka K, Sato H, Matsuoka T. Extremely localized aortic dissection and intussusception of the intimal flap into the left ventricle. Ann Thorac Cardiovasc Surg 2011;17: 431–3. 3. Yang EH, Kwon MH, Mahajan A, et al. Circumferential type A aortic dissection and intimal intussusception of the aorta causing severe aortic regurgitation and obstruction of the left main coronary artery. Echocardiography 2013;30:e81–4. 4. Lajevardi SS, Sian K, Ward M, Marshman D. Circumferential intimal tear in type A aortic dissection with intimo-intimal intussusception into the left ventricle and left main coronary artery occlusion. J Thorac Cardiovasc Surg 2012;144:e21–3. 5. Coady MA, Rizzo JA, Elefteriades JA. Pathologic variants of thoracic aortic dissections: penetrating atherosclerotic ulcers and intramural hematomas. Cardiol Clin 1999;17:637–57. 6. Hufnagel CA, Conrad PW. Intimo-intimal intussusception in dissecting aneurysms. Am J Surg 1962;103:727–31. 7. Lijoi A, Scarano F, Canale C, et al. Circumferential dissection of the ascending aorta with intimal intussusception: case report and review of the literature. Tex Heart Inst J 1994;21:166–9. 8. Come PC, Bivas NK, Sacks B, Thurer BL, Weintraub RM, Axelrod P. Unusual echocardiographic finding in aortic dissection: diastolic prolapse of intimal flap into left ventricle. Am Heart J 1984;107:790–2.

Endovascular Repair of Acute Ascending Aortic Disruption via the Right Axillary Artery Ganesh S. Kumpati, MD, Robert Gray, MD, Amit Patel, MD, and David A. Bull, MD

Comment Ascending aortic dissection with aortic regurgitation caused by intussusception of the proximal intimal flap and accompanying coronary artery disease can be treated with excellent surgical outcome, given the emergency presentation and life-threatening complexity inherent in this pathologic condition. Our experience confirms that in patients with ascending aortic dissection, TEE stands as an invaluable diagnostic utility in defining proximal intimal flap intussusception beyond a continuum of diagnostic facilities including aortography, CT, and transthoracic echocardiography. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc

Divisions of Cardiothoracic Surgery and Pediatric Cardiology, University of Utah, Salt Lake City, Utah

Endovascular repair of emergent syndromes involving the ascending aorta is uncommon. We describe an acute disruption of the ascending aorta during stenting of the pulmonary artery, resulting in an acute aortopulmonary Accepted for publication May 15, 2013. Address correspondence to Dr Kumpati, University of Utah, Division of Cardiothoracic Surgery, 30 N 1900 E, #3C-127, Salt Lake City, UT 84132; e-mail: [email protected].

0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.05.114

artery defect and severe pulmonary edema. The disruption was treated successfully using an endovascular approach, with rapid resolution of the patient’s pulmonary edema. (Ann Thorac Surg 2014;97:700–3) Ó 2014 by The Society of Thoracic Surgeons

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ndovascular repair of aortic disease is an established treatment for select types of descending aortic and aortic arch disease. Endovascular repair has been applied occasionally to the ascending aorta using endovascular devices designed for the abdominal aorta [1–3]. We describe a technique of endovascular repair, via a right axillary artery approach, of an ascending aortic disruption that was noted immediately following bilateral proximal pulmonary artery stent placement in a patient with surgically corrected congenital heart disease.

The patient is a 26-year-old woman with symptomatic bilateral branch pulmonary artery stenoses. D-transposition of the great arteries was diagnosed shortly after birth, and she had initially undergone an arterial switch procedure (LeCompte repair) as a neonate, with a subsequent reoperation for bilateral branch pulmonary artery stenoses at 2 years of age. Preoperative cardiac magnetic resonance imaging demonstrated severe stenoses of the proximal pulmonary arteries bilaterally. The patient was referred for elective percutaneous intervention. In the cardiac catheterization laboratory, using general anesthesia, the pulmonary artery anatomy was confirmed by angiography. Bilateral pulmonary artery angioplasty was performed with subsequent stent placement using a 26-mm Max LD stent dilated to an 18-mm diameter in the proximal left pulmonary artery and a 16-mm Max LD stent dilated to a 16-mm diameter in the proximal right pulmonary artery (ev3 Endovascular, Plymouth, MN). Immediately following placement of the stent in the right pulmonary artery, the distal right pulmonary artery pressure elevated to near systemic levels. Ascending aortic angiography confirmed a disruption of the ascending aorta, with a significant left-to-right shunt (Fig 1A). In addition, the branch pulmonary artery stents appeared to protrude into the ascending aorta (Fig 1B),

CASE REPORT KUMPATI ET AL ENDOVASCULAR REPAIR OF ASCENDING AORTA

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less than 1 cm superior to the origin of the coronary arteries. The patient immediately developed rapidly progressive pulmonary edema and severe hypoxemia, despite high levels of positive pressure mechanical ventilation with 100% oxygen. Surgical consultation was obtained emergently. Conventional surgery would have required emergent replacement of the ascending aorta as well as the main and proximal branch pulmonary arteries. Given her multiple previous sternotomies and her rapidly progressive pulmonary edema, open surgical repair was determined to carry a high risk for morbidity and mortality. Immediate endovascular repair was therefore determined to be the safer and more expedient option. Based on angiographic measurements, the ascending aorta just above the right pulmonary artery was 20 mm. The area of coverage measured approximately 3 cm. Proximal seal would involve placing the proximal margin of the endovascular prosthesis near the ostia of the coronary arteries. Cutdown exposure to the right axillary artery was obtained via a transverse incision in the axilla. A pursestring suture of 5-0 Prolene was placed, and arterial access was obtained using a 6-French sheath. Heparin was administered to maintain an activated clotting time greater than 250 s. A Bentsen guidewire was advanced into the ascending aorta. An AL-1 guide catheter was used to advance the guidewire into the left ventricle. An exchangelength Amplatz guidewire with a floppy J-tip was positioned in the apex of the left ventricle. The 6-French sheath was then exchanged for a 16-French sheath. A 5-French transvenous pacing catheter was placed in the right ventricle via a femoral venous approach. Endovascular repair was performed using two Gore Excluder aortic cuffs (23 mm  3.3 cm). The Gore Excluder device is designed for placement into the abdominal aorta via a femoral artery approach (61-cm delivery catheter). The device was placed via the sheath in the axillary artery. After positioning, the device was deployed during a brief period of rapid ventricular pacing to 180 beats/min and was expanded with a Coda balloon during an additional period of rapid ventricular pacing. Fig 1. (A) Anteroposterior and (B) lateral angiographic images of ascending aortic disruption demonstrating an acute aortopulmonary window with pulmonary artery filling during aortic angiogram (arrowheads) and a pulmonary artery stent protruding into the ascending aortic lumen.

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Ann Thorac Surg 2014;97:700–3

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CASE REPORT KUMPATI ET AL ENDOVASCULAR REPAIR OF ASCENDING AORTA

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After initial placement of the device, a proximal type I endoleak was identified. A second Gore Excluder cuff (23 mm  3.3 cm) was placed to achieve further proximal coverage in the ascending aorta during a brief period of rapid ventricular pacing, and it was expanded with a Coda balloon during an additional period of rapid ventricular pacing. The pulmonary artery stents were noted to compress slightly and anteriorly during balloon expansion (Fig 2), after which there was a complete seal of the ascending aorta (Fig 3). The patient’s respiratory status stabilized and her oxygenation improved immediately. The sheath was removed from the right axillary artery, and the arterial access site was closed with a 5-0 Prolene suture. Normal distal perfusion was confirmed following sheath removal. Repeated right heart catheterization demonstrated adequate relief of the branch pulmonary artery stenoses with right ventricular pressures that were approximately half of the systemic pressures, with no evidence of persistent left to right shunting. Wound closure was then performed with concomitant groin sheath removal, and hemostasis was achieved using direct pressure. The patient recovered rapidly. She was extubated within 24 hours of the procedure and was discharged to home in 3 days. At her clinic follow-up 4 weeks later, she was asymptomatic. An echocardiogram and a CT scan were performed for postintervention surveillance. The CT scan demonstrated the proximal extent of the ascending endograft to be slightly below and posterior to the anteriorly located right coronary artery (Fig 4). As the patient remains asymptomatic with normal biventricular systolic function, no additional intervention has been undertaken.

Fig 2. Deployment of a second endovascular stent graft in the ascending aorta.

Ann Thorac Surg 2014;97:700–3

Fig 3. Angiographic image of the ascending aorta demonstrating seal of aortic disruption.

Close follow-up and monitoring of the patient’s status is planned.

Comment Endovascular repair of focal pathology in the ascending aorta via the left ventricular apex and the carotid artery has been described previously [1, 4]. The technique presented here was modeled after transcatheter aortic valve replacement via the axillary artery [5]. The approach via the right axillary artery is familiar to cardiovascular surgeons and avoids a direct incision into the thorax.

Fig 4. Postoperative CT angiogram showing partial coverage of the right coronary artery (RCA) ostium.

Ann Thorac Surg 2014;97:703–5

CASE REPORT KUWAUCHI ET AL REIMPLANTATION FOR THE TRUNCAL VALVE

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Endovascular repair was selected for this patient in extremis. Partial coverage of the right coronary artery ostium occurred in this case. The placement of the endovascular stent graft adjacent to the ostium of the right coronary artery was intentional in this case in order to obtain a proximal seal with the second device. There is a narrow margin for success with endovascular intervention in the ascending aorta. Currently, this narrow margin makes endovascular intervention for ascending aortic pathology appropriate only for cases with a high risk for morbidity and mortality with open surgical repair. The future development of endografts designed specifically for ascending aortic intervention [6, 7] will increase the applicability of endovascular repair for ascending aortic disease.

We describe here an initial successful case of valvesparing surgery using reimplantation technique in a 24-year-old male with aortic root dilatation with truncal valve insufficiency after common arterial trunk repair. Concomitant right ventricular outflow tract reconstruction with expanded polytetrafluoroethylene was also successfully performed. He was discharged home on postoperative day 10 without stenosis or regurgitation of repaired valves. He is in New York Heart Association class I condition without any anticoagulant agents 6 months after operation. Of course, careful follow-up will be needed though our early result is acceptable. (Ann Thorac Surg 2014;97:703–5) Ó 2014 by The Society of Thoracic Surgeons

References

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Valve-Sparing Root Replacement Surgery for the Truncal Valve in an Adult: Report of the Initial Successful Case Shintaro Kuwauchi, MD, Kohei Kawazoe, MD, PhD, Kozo Matsuo, MD, Kohei Abe, MD, Manabu Yamasaki, MD, Joji Ito, MD, and Sunao Watanabe, MD Division of Cardiovascular Surgery, Cardiovascular Center, St. Luke’s International Hospital, Tokyo; and Department of Cardiovascular Surgery, Chiba Cardiovascular Center, Chiba, Japan Accepted for publication June 7, 2013. Address correspondence to Dr Kuwauchi, Division of Cardiovascular Surgery, Cardiovascular Center, St. Luke’s International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo 104-8560, Japan; e-mail: [email protected].

Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc

A 24-year-old male was referred to our hospital because of aortic root dilatation with TVI and RVOT stenosis. He was diagnosed as CAT (Collette-Edwards II) and had repaired by a Rastelli procedure at age 1, and conduit replacement was performed at age 6. He had had 2 percutaneous transcatheter angioplasty procedures for peripheral pulmonary artery stenosis and a catheter ablation for non-sustained ventricular tachycardia. On referral, an electrocardiography showed sinus rhythm and a chest X-ray film showed slight cardiomegaly, but no sign of congestion. An echocardiography revealed mild to moderate TVI. The left ventricular end-diastolic diameter was 44 mm and left ventricular ejection fraction 0.71. The RVOT stenosis was obvious because peak velocity was 4.0m/second. Computed tomography demonstrated the dilatation of the sinus of Valsalva to a diameter of 46 mm, aortic annulus of 29  36 mm, and sinotubular junction of 32  37 mm. Surgery was performed through a median resternotomy and the patient was placed on cardiopulmonary bypass. After complete removal of the RVOT conduit, the ascending aorta was cross-clamped and cardiac arrest was obtained by an antegrade root cardioplegia. The truncal valve was confirmed to be bicuspid and both leaflets had a raphe without prolapse. Because leaflets were pliable enough, reimplantation of the aortic root was performed as reported by David and Feindel [1]. The dilated sinuses of Valsalva were excised and the truncal valve was reimplanted into a 28-mm Triplex graft (Vascutek Terumo, Tokyo, Japan) with 4-0 monofilament sutures, so as to correspond to 2 commissures. The coronary ostia were also reimplanted. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.06.104

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1. Ailawadi G, Lim DS, Peeler BB, Matsumoto AH, Dake MD. Traumatic ascending aortopulmonary window following pulmonary artery stent dilatation: therapy with aortic endovascular stent graft. Pediatr Cardiol 2007;28:305–8. 2. Gelpi G, Cagnoni G, Vanelli P, Antona C. Endovascular repair of ascending aortic pseudoaneurysm in a high-risk patient. Interact Cardiovasc Thorac Surg 2012;14:494–6. 3. Kolvenbach RR, Karmeli R, Pinter LS, et al. Endovascular management of ascending aortic pathology. J Vasc Surg 2011;53:1431–7. 4. Uthoff H, Garcia-Covarrubias L, Samuels S, Benenati JF, Moreno NL, Katzen BT. Transapical endovascular aortic repair to treat complex aortic pathologies. Ann Thorac Surg 2012;93:1735–7. 5. Caceres M, Braud R, Roselli EE. The axillary/subclavian artery access route for transcatheter aortic valve replacement: a systematic review of the literature. Ann Thorac Surg 2012;93:1013–8. 6. Metcalfe MJ, Karthikesalingam A, Black SA, Loftus IM, Morgan R, Thompson MM. The first endovascular repair of an acute type A dissection using an endograft designed for the ascending aorta. J Vasc Surg 2012;55:220–2. 7. Mewhort HE, Appoo JJ, Sumner GL, Herget E, Wong J. Alternative surgical approach to repair of the ascending aorta. Ann Thorac Surg 2011;92:1108–10.

ommon arterial trunk (CAT) is a rare cardiovascular malformation. Although physiological repair is performed in neonate or infancy, reoperation will be necessary relating to conduit stenosis and truncal valve insufficiency (TVI) or stenosis. We report herein an initial successful case of valve-sparing surgery using reimplantation technique in an adult patient with aortic root dilatation with TVI after CAT repair. Concomitant right ventricular outflow tract (RVOT) reconstruction was successfully performed.

Endovascular repair of acute ascending aortic disruption via the right axillary artery.

Endovascular repair of emergent syndromes involving the ascending aorta is uncommon. We describe an acute disruption of the ascending aorta during ste...
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