HOW TO DO IT
Hybrid Treatment for Type A Acute Aortic Dissection With Multiorgan Malperfusion Koyu Tanaka, MD, Genta Chikazawa, MD, Taichi Sakaguchi, MD, Toshinori Totsugawa, MD, Kentaro Tamura, MD, and Hidenori Yoshitaka, MD Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
FEATURE ARTICLES
We present a hybrid surgical and endovascular repair for type A aortic dissection complicated with visceral ischemia. The patient had a history of coronary artery bypass grafting using the right gastroepiploic artery bypassed to the left anterior descending artery. Because of exacerbated metabolic acidosis and coronary ischemia caused by insufficient blood flow of the celiac artery and the superior mesenteric artery, the percutaneous
transluminal angioplasty for both arteries was performed before surgical central repair. Hybrid operating room settings and equipment are considered to be a feasible option for treating patients with type A aortic dissection complicated with vital organ malperfusion.
I
admission, abdominal tenderness gradually worsened. In addition, metabolic acidosis was exacerbated, and a large amount of tarry stool, probably caused by gut ischemia, was identified. We decided to perform the hybrid surgical operation for type A acute aortic dissection complicated with visceral malperfusion.
n recent decades, numerous innovations have significantly improved the surgical outcome of type A acute aortic dissection. However, the mortality rate remains high because of preoperative complications, such as organ malperfusion. Specifically, mesenteric ischemia is a significant risk factor for surgical mortality after surgical repair for type A aortic dissection. We demonstrate the successful management of a case complicated with mesenteric ischemia secondary to type A acute aortic dissection by one-staged hybrid surgical and endovascular treatment. A 57-year-old man was admitted to our institution complaining of abdominal pain. He had a history of laparotomy for harvesting the right gastroepiploic artery (rGEA) and had previously received coronary artery bypass grafting using the left internal thoracic artery (LITA) bypassed to the first diagonal branch and rGEA to the left anterior descending artery (LAD) through midline sternotomy. On admission, the electrocardiogram (ECG) showed ST segment depression in anterior leads (V1–V4). Contrastenhanced computed tomography (CT) scan revealed Stanford type A aortic dissection extending from the ascending aorta to the iliac bifurcation (Figs 1A, 1B). The celiac artery (CA), the superior mesenteric artery (SMA), and the left renal artery were compressed by a false lumen (Figs 1C– 1E). The CA and the SMA were perfused from the true lumen. The maximum diameter of the superior mesenteric vein was significantly narrower than that of the SMA (Fig 1F) [1]. Neither the compression of the coronary arteries nor pericardial tamponade were identified in the preoperative transthoracic echocardiography. After
Accepted for publication Jan 17, 2014. Address correspondence to Dr Tanaka, Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1 Nakaichou, Kita-ku, Okayama, 700-0804, Japan; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2014;98:1118–20) Ó 2014 by The Society of Thoracic Surgeons
Technique The level of ischemia of the vital organs was investigated with the use of the abdominal fluorescent angiography and general anesthesia. Angiographic findings showed poor blood flow of the CA and the SMA (Fig 2). In addition, percutaneous transluminal angioplasty (PTA) was performed for stenosis of the SMA orifice with the balloon-expandable 9.0 37-mm Express vascular LD stent (Boston Scientific, Natick, MA) under the guidance of intravascular ultrasound, followed by PTA for the stenosis of the CA with a balloon-expandable 9.0 37-mm Express vascular LD stent. After ensuring sufficient blood flow into the true lumens of the SMA and the CA, the intraoperative ECG showed the ST segment depression and immediately returned to the base line. Subsequently, central aortic repair was initiated. After establishing of cardiopulmonary bypass (CPB) through the right groin, chest reentry through the midline sternotomy was carefully performed to avoid injuring the LITA. Total aortic arch replacement using the four-branched prosthetic graft was performed under deep hypothermic circulatory arrest with selective antegrade cerebral perfusions. The operative time, CPB time, cardiac arrest time, and circulatory arrest time was 543 min, 338 min, 151 min, and 60 min, respectively. Metabolic acidosis significantly improved by the end of the operation. The patient’s postoperative course was uneventful, and the follow-up CT scan 10 months after the operation revealed no significant findings. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.01.079
Ann Thorac Surg 2014;98:1118–20
HOW TO DO IT TANAKA ET AL HYBRID THERAPY FOR TYPE A DISSECTION
1119
FEATURE ARTICLES
Fig 1. (A, B) Contrast-enhanced computed tomography scan revealed Stanford type A aortic dissection extending from the ascending aorta to the iliac bifurcation. The (C) celiac artery, (D) superior mesenteric artery, and (E) left renal artery were compressed by the thrombosed false lumen. (F) The ratio of the maximum diameter of the superior mesenteric vein (white arrowhead) to that of the superior mesenteric artery (black arrowhead) was less than 1.0.
Comment Although there have been great innovations in operative techniques, procedural strategies, and intensive care management over the last decade, the mortality rate for type A acute aortic dissection remains high [2]. Specifically, acute aortic dissection with vital organ malperfusion worsens operative outcome [3–6]. The incidence of mesenteric ischemia coupled with aortic dissection is rare (1.4%) in published studies [3]. However, the in-hospital mortality of those patients is extremely high, ranging from 30% to 75% [3–5]. In our case, the patient suffered from acute aortic dissection complicated with mesenteric ischemia. Furthermore, the blood flow of the LAD was dependent on that of the GEA graft, which was exacerbated because of stenosis of the CA and the SMA. Theoretically, organ malperfusion should return to normal after central aortic surgical repair. Unfortunately, the visceral arteries are at times compressed by a thrombosed false lumen. Therefore, treatment priority is still in debate (PTA first or surgical central repair first) in cases of acute type A aortic dissection complicated with visceral
organ ischemia. Fabre and colleagues [7] reported successful management of percutaneous intervention for mesenteric malperfusion with type A dissection. They described that immediate aortic operation on patients with mesenteric complications protects them from aortic rupture, but results in increased ischemia if the aortic replacement does not restore adequate blood flow in the visceral arteries. Knowing that mesenteric ischemia could lead to fatal necrosis of the intestines if not treated as soon as possible, we were concerned about the time required for surgical dissection of the dense adhesion inside the pericardial cavity (because of previous surgery) before the completion of central aortic repair. In addition, emergency surgical intervention for the CA and the SMA under redo laparotomy was considered to be challenging for this case. Furthermore, the dense adhesion, as stated earlier, was thought to be protective against aortic rupture to some extent. Therefore, we chose endovascular treatment for the visceral ischemia as a first priority, followed by the central aortic surgical repair. Although we prepared for redo laparotomy to
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HOW TO DO IT TANAKA ET AL HYBRID THERAPY FOR TYPE A DISSECTION
Ann Thorac Surg 2014;98:1118–20
inspect progressive intestinal ischemia after the operation, it was not subsequently required because of the significant improvement in the peritoneal signs and metabolic acidosis postoperatively. By prioritizing prompt hybrid treatment, we believe that we can save those patients suffering from acute type A aortic dissection complicated with vital organ malperfusion.
References
FEATURE ARTICLES Fig 2. Angiography revealed poor blood flow of the superior mesenteric celiac artery (white arrowhead) and the peripheral colic arteries (black arrowheads).
1. Kurimoto Y, Morishita K, Fukuda J, et al. A simple but useful method of screening for mesenteric ischemia secondary to acute aortic dissection. Surgery 2004;136:42–6. 2. Rampoldi V, Trimarchi S, Eagle KA, et al. Simple risk models to predict surgical mortality in acute type A aortic dissection: the international registry of acute aortic dissection score. Ann Thorac Surg 2007;83:55–61. 3. Geirsson A, Szeto WY, Pochettino A, et al. Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection: outcomes and need for additional revascularizations. Eur J Cardiothorac Surg 2007;32: 255–62. 4. Girdauskas E, Kuntze T, Borger MA, Falk V, Mohr FW. Surgical risk of preoperative malperfusion in acute type A aortic dissection. J Thorac Cardiovasc Surg 2009;138:1363–9. 5. Trimarchi S, Nienaber CA, Rampoldi V, et al. Contemporary results of surgery in acute type A aortic dissection: the international registry of acute aortic dissection experience. J Thorac Cardiovasc Surg 2005;129:112–22. 6. Pacini D, Leone A, Belotti LMB, et al. Acute type A dissection: significance of multiorgan malperfusion. Eur J Cardiothorac Surg 2013;43:820–6. 7. Fabre O, Vincentelli A, Willoteaux S, Beregi JP, Prat A. Preoperative fenestration for type A acute aortic dissection with mesenteric malperfusion. Ann Thorac Surg 2002;73: 950–1.
Hybrid Treatment for Type A Acute Aortic Dissection With Multiorgan Malperfusion Koyu Tanaka, MD, Genta Chikazawa, MD, Taichi Sakaguchi, MD, Toshinori Totsugawa, MD, Kentaro Tamura, MD, and Hidenori Yoshitaka, MD Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
FEATURE ARTICLES
We present a hybrid surgical and endovascular repair for type A aortic dissection complicated with visceral ischemia. The patient had a history of coronary artery bypass grafting using the right gastroepiploic artery bypassed to the left anterior descending artery. Because of exacerbated metabolic acidosis and coronary ischemia caused by insufficient blood flow of the celiac artery and the superior mesenteric artery, the percutaneous
transluminal angioplasty for both arteries was performed before surgical central repair. Hybrid operating room settings and equipment are considered to be a feasible option for treating patients with type A aortic dissection complicated with vital organ malperfusion.
I
admission, abdominal tenderness gradually worsened. In addition, metabolic acidosis was exacerbated, and a large amount of tarry stool, probably caused by gut ischemia, was identified. We decided to perform the hybrid surgical operation for type A acute aortic dissection complicated with visceral malperfusion.
n recent decades, numerous innovations have significantly improved the surgical outcome of type A acute aortic dissection. However, the mortality rate remains high because of preoperative complications, such as organ malperfusion. Specifically, mesenteric ischemia is a significant risk factor for surgical mortality after surgical repair for type A aortic dissection. We demonstrate the successful management of a case complicated with mesenteric ischemia secondary to type A acute aortic dissection by one-staged hybrid surgical and endovascular treatment. A 57-year-old man was admitted to our institution complaining of abdominal pain. He had a history of laparotomy for harvesting the right gastroepiploic artery (rGEA) and had previously received coronary artery bypass grafting using the left internal thoracic artery (LITA) bypassed to the first diagonal branch and rGEA to the left anterior descending artery (LAD) through midline sternotomy. On admission, the electrocardiogram (ECG) showed ST segment depression in anterior leads (V1–V4). Contrastenhanced computed tomography (CT) scan revealed Stanford type A aortic dissection extending from the ascending aorta to the iliac bifurcation (Figs 1A, 1B). The celiac artery (CA), the superior mesenteric artery (SMA), and the left renal artery were compressed by a false lumen (Figs 1C– 1E). The CA and the SMA were perfused from the true lumen. The maximum diameter of the superior mesenteric vein was significantly narrower than that of the SMA (Fig 1F) [1]. Neither the compression of the coronary arteries nor pericardial tamponade were identified in the preoperative transthoracic echocardiography. After
Accepted for publication Jan 17, 2014. Address correspondence to Dr Tanaka, Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1 Nakaichou, Kita-ku, Okayama, 700-0804, Japan; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2014;98:1118–20) Ó 2014 by The Society of Thoracic Surgeons
Technique The level of ischemia of the vital organs was investigated with the use of the abdominal fluorescent angiography and general anesthesia. Angiographic findings showed poor blood flow of the CA and the SMA (Fig 2). In addition, percutaneous transluminal angioplasty (PTA) was performed for stenosis of the SMA orifice with the balloon-expandable 9.0 37-mm Express vascular LD stent (Boston Scientific, Natick, MA) under the guidance of intravascular ultrasound, followed by PTA for the stenosis of the CA with a balloon-expandable 9.0 37-mm Express vascular LD stent. After ensuring sufficient blood flow into the true lumens of the SMA and the CA, the intraoperative ECG showed the ST segment depression and immediately returned to the base line. Subsequently, central aortic repair was initiated. After establishing of cardiopulmonary bypass (CPB) through the right groin, chest reentry through the midline sternotomy was carefully performed to avoid injuring the LITA. Total aortic arch replacement using the four-branched prosthetic graft was performed under deep hypothermic circulatory arrest with selective antegrade cerebral perfusions. The operative time, CPB time, cardiac arrest time, and circulatory arrest time was 543 min, 338 min, 151 min, and 60 min, respectively. Metabolic acidosis significantly improved by the end of the operation. The patient’s postoperative course was uneventful, and the follow-up CT scan 10 months after the operation revealed no significant findings. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.01.079
Ann Thorac Surg 2014;98:1118–20
HOW TO DO IT TANAKA ET AL HYBRID THERAPY FOR TYPE A DISSECTION
1119
FEATURE ARTICLES
Fig 1. (A, B) Contrast-enhanced computed tomography scan revealed Stanford type A aortic dissection extending from the ascending aorta to the iliac bifurcation. The (C) celiac artery, (D) superior mesenteric artery, and (E) left renal artery were compressed by the thrombosed false lumen. (F) The ratio of the maximum diameter of the superior mesenteric vein (white arrowhead) to that of the superior mesenteric artery (black arrowhead) was less than 1.0.
Comment Although there have been great innovations in operative techniques, procedural strategies, and intensive care management over the last decade, the mortality rate for type A acute aortic dissection remains high [2]. Specifically, acute aortic dissection with vital organ malperfusion worsens operative outcome [3–6]. The incidence of mesenteric ischemia coupled with aortic dissection is rare (1.4%) in published studies [3]. However, the in-hospital mortality of those patients is extremely high, ranging from 30% to 75% [3–5]. In our case, the patient suffered from acute aortic dissection complicated with mesenteric ischemia. Furthermore, the blood flow of the LAD was dependent on that of the GEA graft, which was exacerbated because of stenosis of the CA and the SMA. Theoretically, organ malperfusion should return to normal after central aortic surgical repair. Unfortunately, the visceral arteries are at times compressed by a thrombosed false lumen. Therefore, treatment priority is still in debate (PTA first or surgical central repair first) in cases of acute type A aortic dissection complicated with visceral
organ ischemia. Fabre and colleagues [7] reported successful management of percutaneous intervention for mesenteric malperfusion with type A dissection. They described that immediate aortic operation on patients with mesenteric complications protects them from aortic rupture, but results in increased ischemia if the aortic replacement does not restore adequate blood flow in the visceral arteries. Knowing that mesenteric ischemia could lead to fatal necrosis of the intestines if not treated as soon as possible, we were concerned about the time required for surgical dissection of the dense adhesion inside the pericardial cavity (because of previous surgery) before the completion of central aortic repair. In addition, emergency surgical intervention for the CA and the SMA under redo laparotomy was considered to be challenging for this case. Furthermore, the dense adhesion, as stated earlier, was thought to be protective against aortic rupture to some extent. Therefore, we chose endovascular treatment for the visceral ischemia as a first priority, followed by the central aortic surgical repair. Although we prepared for redo laparotomy to
1120
HOW TO DO IT TANAKA ET AL HYBRID THERAPY FOR TYPE A DISSECTION
Ann Thorac Surg 2014;98:1118–20
inspect progressive intestinal ischemia after the operation, it was not subsequently required because of the significant improvement in the peritoneal signs and metabolic acidosis postoperatively. By prioritizing prompt hybrid treatment, we believe that we can save those patients suffering from acute type A aortic dissection complicated with vital organ malperfusion.
References
FEATURE ARTICLES Fig 2. Angiography revealed poor blood flow of the superior mesenteric celiac artery (white arrowhead) and the peripheral colic arteries (black arrowheads).
1. Kurimoto Y, Morishita K, Fukuda J, et al. A simple but useful method of screening for mesenteric ischemia secondary to acute aortic dissection. Surgery 2004;136:42–6. 2. Rampoldi V, Trimarchi S, Eagle KA, et al. Simple risk models to predict surgical mortality in acute type A aortic dissection: the international registry of acute aortic dissection score. Ann Thorac Surg 2007;83:55–61. 3. Geirsson A, Szeto WY, Pochettino A, et al. Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection: outcomes and need for additional revascularizations. Eur J Cardiothorac Surg 2007;32: 255–62. 4. Girdauskas E, Kuntze T, Borger MA, Falk V, Mohr FW. Surgical risk of preoperative malperfusion in acute type A aortic dissection. J Thorac Cardiovasc Surg 2009;138:1363–9. 5. Trimarchi S, Nienaber CA, Rampoldi V, et al. Contemporary results of surgery in acute type A aortic dissection: the international registry of acute aortic dissection experience. J Thorac Cardiovasc Surg 2005;129:112–22. 6. Pacini D, Leone A, Belotti LMB, et al. Acute type A dissection: significance of multiorgan malperfusion. Eur J Cardiothorac Surg 2013;43:820–6. 7. Fabre O, Vincentelli A, Willoteaux S, Beregi JP, Prat A. Preoperative fenestration for type A acute aortic dissection with mesenteric malperfusion. Ann Thorac Surg 2002;73: 950–1.
