Case Study
Retrograde ascending aortic dissection after thoracic endovascular aortic repair
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(7) 864–865 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314527593 aan.sagepub.com
Tomoya Yoshizaki and Dai Tasaki
Abstract Thoracic endovascular aortic repair is a valuable alternative treatment option for patients with thoracic aortic aneurysms and type B dissections. However, thoracic endovascular aortic repair is associated with the risk of previously unanticipated severe complications including retrograde ascending aortic dissection. We report the case of an 86-year-old man who developed retrograde ascending aortic dissection as a delayed complication of thoracic endovascular aortic repair. Open surgical repair resulted in a successful outcome.
Keywords Aneurysm, dissecting, Aortic aneurysm, thoracic, Blood vessel prosthesis implantation, Postoperative complications, Stents
Introduction Thoracic endovascular aortic repair (TEVAR) of the descending thoracic aorta is an alternative to conventional open surgery. An increasing number of studies have demonstrated that TEVAR achieves a short-term result as good as that of surgical repair for the treatment of descending aortic aneurysms, with fewer complications.1 Retrograde ascending aortic dissection (rAAD) is one of several potentially lethal complications of TEVAR that have been reported.2 We present a case of rAAD that developed as a delayed complication of TEVAR.
Case report An 86-year-old man was admitted electively with an asymptomatic saccular distal arch aortic aneurysm that expanded within short period time (maximum diameter 42 mm). We performed TEVAR of the distal arch using 2 Talent stent grafts, P 36 114 mm þ D 40 114 mm (Medtronic Vascular, Santa Rosa, CA, USA). Although the predischarge computed tomography (CT) scan revealed a type 1 a endoleak, the patient’s postoperative course was uneventful and he was discharged. However, the type 1 a endoleak worsened and he was once again admitted electively 2 months after the initial TEVAR. We performed
TEVAR to cover the left subclavian artery proximal to the previous stent grafts, using one Talent stent graft (40 114 mm). A postoperative CT scan revealed no endoleak and the patient was discharged uneventfully on postoperative day 5. Three months later, the asymptomatic patient visited our outpatient clinic for a follow-up study, and we observed rAAD on a CT scan performed a week earlier (Figure 1). He underwent urgent ascending aorta and aortic arch replacement including the brachiocephalic and left carotid artery, with a 26-mm J-GRAFT prosthesis. Intraoperatively, a dissection entry caused by bare metal spring perforation of the enlarged ascending aorta was confirmed. This bare metal spring was not covered by intima (Figure 2). We also employed the elephant trunk technique with a 32-mm Hemashield prosthetic graft, and the dissected layers were reapproximated with fibrin glue. Distal anastomosis was performed with 4/0 polypropylene mattress sutures, sandwiching the aortic wall attaching the bare metal springs between the elephant Department of Cardiovascular Surgery, Musashino Red Cross Hospital, Tokyo, Japan Corresponding author: Tomoya Yoshizaki, MD, Department of Cardiovascular Surgery, Musashino Red Cross Hospital, 1-26-1 Kyounan-cho, Musashino-shi, Tokyo, 180-8610, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at Northeastern University on November 14, 2015
Yoshizaki and Tasaki
865
Figure 1. Enhanced computed tomography demonstrating retrograde ascending aortic dissection just proximal to the tips of a proximal bare metal spring (white arrowhead).
dilated ascending aortic diameter 540 mm and/or a zone 0 native proximal landing zone. Although this case was not aortic dissection nor Marfan syndrome, the combination of dilated ascending aortic wall (43 mm) and a proximal landing zone at the lesser curve in the native ascending aorta (zone 0) may have caused the development of rAAD. An interesting finding was that intima tears are typically located at the tips of proximal bare metal springs2, as was seen in this case. The proximal bare metal spring is designed to open widely without constraint by the polyester graft, and provide a strong radial force to strengthen proximal fixation. In this case, only one proximal bare metal spring at the lesser curve was not covered by intima. This suggests that the proximal bare metal spring was not fixed to the intima, and may have made the dissection entry late in the postoperative period. Emergency surgery for rAAD nearly always requires total arch replacement.2 An alternative approach to conventional total arch replacement is anastomosis of the distal end. Other reports suggest that the proximal bare metal springs should be cut1, but in this case, the springs were not cut, so we sandwiched the aortic wall attaching these springs between the elephant trunk graft and felt strips, using mattress sutures. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Figure 2. Operative photograph revealing the intimal tear located at the tips of a proximal bare metal spring, the only proximal bare metal spring at the lesser curve not covered by intima (black arrowheads).
Conflict of interest statement None declared.
References trunk graft and felt strips. No bare metal spring was cut off. The patient was extubated on postoperative day 1, and a routine postoperative CT scan revealed no endoleak. He was discharged uneventfully on postoperative day 10.
Discussion Retrograde ascending aortic dissection is a rare but lethal complication of TEVAR,2 with an incidence of 1.33%–6.8%.3 Data from the 2009 European registry on endovascular aortic repair suggest that the cause of rAAD was aortic dissection in 81% of patients, and 83% involved devices with proximal bare metal springs, with a mortality rate of 42%.3 A fragile aortic wall due to aortic dissection or Marfan syndrome is considered a cause of rAAD.4 Williams and colleagues2 mentioned that the risk of rAAD appears especially high with a
1. Nienaber CA, Fattori R, Lund G, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999; 340: 1539–1545. 2. Williams JB, Andersen ND, Bhattacharya SD, et al. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg 2012; 55: 1255–1262. 3. Eggebrecht H, Thompson M, Rousseau H, et al. Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications. Circulation 2009; 120: S276–S281. 4. Dong ZH, Fu WG, Wang YQ, et al. Retrograde type A aortic dissection after endovascular stent graft placement for treatment of type B dissection. Circulation 2009; 119: 735–741. 5. Desai ND. Techniques for repair of retrograde aortic dissection following thoracic endovascular aortic repair. Ann Cardiothorac Surg 2013; 2: 369–371.
Downloaded from aan.sagepub.com at Northeastern University on November 14, 2015
Retrograde ascending aortic dissection after thoracic endovascular aortic repair
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(7) 864–865 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314527593 aan.sagepub.com
Tomoya Yoshizaki and Dai Tasaki
Abstract Thoracic endovascular aortic repair is a valuable alternative treatment option for patients with thoracic aortic aneurysms and type B dissections. However, thoracic endovascular aortic repair is associated with the risk of previously unanticipated severe complications including retrograde ascending aortic dissection. We report the case of an 86-year-old man who developed retrograde ascending aortic dissection as a delayed complication of thoracic endovascular aortic repair. Open surgical repair resulted in a successful outcome.
Keywords Aneurysm, dissecting, Aortic aneurysm, thoracic, Blood vessel prosthesis implantation, Postoperative complications, Stents
Introduction Thoracic endovascular aortic repair (TEVAR) of the descending thoracic aorta is an alternative to conventional open surgery. An increasing number of studies have demonstrated that TEVAR achieves a short-term result as good as that of surgical repair for the treatment of descending aortic aneurysms, with fewer complications.1 Retrograde ascending aortic dissection (rAAD) is one of several potentially lethal complications of TEVAR that have been reported.2 We present a case of rAAD that developed as a delayed complication of TEVAR.
Case report An 86-year-old man was admitted electively with an asymptomatic saccular distal arch aortic aneurysm that expanded within short period time (maximum diameter 42 mm). We performed TEVAR of the distal arch using 2 Talent stent grafts, P 36 114 mm þ D 40 114 mm (Medtronic Vascular, Santa Rosa, CA, USA). Although the predischarge computed tomography (CT) scan revealed a type 1 a endoleak, the patient’s postoperative course was uneventful and he was discharged. However, the type 1 a endoleak worsened and he was once again admitted electively 2 months after the initial TEVAR. We performed
TEVAR to cover the left subclavian artery proximal to the previous stent grafts, using one Talent stent graft (40 114 mm). A postoperative CT scan revealed no endoleak and the patient was discharged uneventfully on postoperative day 5. Three months later, the asymptomatic patient visited our outpatient clinic for a follow-up study, and we observed rAAD on a CT scan performed a week earlier (Figure 1). He underwent urgent ascending aorta and aortic arch replacement including the brachiocephalic and left carotid artery, with a 26-mm J-GRAFT prosthesis. Intraoperatively, a dissection entry caused by bare metal spring perforation of the enlarged ascending aorta was confirmed. This bare metal spring was not covered by intima (Figure 2). We also employed the elephant trunk technique with a 32-mm Hemashield prosthetic graft, and the dissected layers were reapproximated with fibrin glue. Distal anastomosis was performed with 4/0 polypropylene mattress sutures, sandwiching the aortic wall attaching the bare metal springs between the elephant Department of Cardiovascular Surgery, Musashino Red Cross Hospital, Tokyo, Japan Corresponding author: Tomoya Yoshizaki, MD, Department of Cardiovascular Surgery, Musashino Red Cross Hospital, 1-26-1 Kyounan-cho, Musashino-shi, Tokyo, 180-8610, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at Northeastern University on November 14, 2015
Yoshizaki and Tasaki
865
Figure 1. Enhanced computed tomography demonstrating retrograde ascending aortic dissection just proximal to the tips of a proximal bare metal spring (white arrowhead).
dilated ascending aortic diameter 540 mm and/or a zone 0 native proximal landing zone. Although this case was not aortic dissection nor Marfan syndrome, the combination of dilated ascending aortic wall (43 mm) and a proximal landing zone at the lesser curve in the native ascending aorta (zone 0) may have caused the development of rAAD. An interesting finding was that intima tears are typically located at the tips of proximal bare metal springs2, as was seen in this case. The proximal bare metal spring is designed to open widely without constraint by the polyester graft, and provide a strong radial force to strengthen proximal fixation. In this case, only one proximal bare metal spring at the lesser curve was not covered by intima. This suggests that the proximal bare metal spring was not fixed to the intima, and may have made the dissection entry late in the postoperative period. Emergency surgery for rAAD nearly always requires total arch replacement.2 An alternative approach to conventional total arch replacement is anastomosis of the distal end. Other reports suggest that the proximal bare metal springs should be cut1, but in this case, the springs were not cut, so we sandwiched the aortic wall attaching these springs between the elephant trunk graft and felt strips, using mattress sutures. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Figure 2. Operative photograph revealing the intimal tear located at the tips of a proximal bare metal spring, the only proximal bare metal spring at the lesser curve not covered by intima (black arrowheads).
Conflict of interest statement None declared.
References trunk graft and felt strips. No bare metal spring was cut off. The patient was extubated on postoperative day 1, and a routine postoperative CT scan revealed no endoleak. He was discharged uneventfully on postoperative day 10.
Discussion Retrograde ascending aortic dissection is a rare but lethal complication of TEVAR,2 with an incidence of 1.33%–6.8%.3 Data from the 2009 European registry on endovascular aortic repair suggest that the cause of rAAD was aortic dissection in 81% of patients, and 83% involved devices with proximal bare metal springs, with a mortality rate of 42%.3 A fragile aortic wall due to aortic dissection or Marfan syndrome is considered a cause of rAAD.4 Williams and colleagues2 mentioned that the risk of rAAD appears especially high with a
1. Nienaber CA, Fattori R, Lund G, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999; 340: 1539–1545. 2. Williams JB, Andersen ND, Bhattacharya SD, et al. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg 2012; 55: 1255–1262. 3. Eggebrecht H, Thompson M, Rousseau H, et al. Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications. Circulation 2009; 120: S276–S281. 4. Dong ZH, Fu WG, Wang YQ, et al. Retrograde type A aortic dissection after endovascular stent graft placement for treatment of type B dissection. Circulation 2009; 119: 735–741. 5. Desai ND. Techniques for repair of retrograde aortic dissection following thoracic endovascular aortic repair. Ann Cardiothorac Surg 2013; 2: 369–371.
Downloaded from aan.sagepub.com at Northeastern University on November 14, 2015
