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Eur J Cardiothorac Surg 2001;20:1057-1058
© 2001 Elsevier Science NL

Case report

Emergency surgery for retrograde extension of type B dissection after endovascular stent graft repair

^a Università ‘La Sapienza’ II-div. Cardiochirurgia, viale del Policlinico 155, 00161 Rome, Italy
^b Istituto di Radiologia -Policlinico Umberto I Rome, Italy

Received 11 June 2001; received in revised form 28 July 2001; accepted 6 August 2001.

Corresponding author. Tel.: +39-06-49972693; fax: +39-06-49972410
e-mail: marcototaro{at}virgilio.it

	Abstract

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion References

 
Endovascular stent graft repair of type B dissection is a new and alternative treatment to the surgical or medical therapy. This technique is not free from minor or major complications and we herein report the case of a patient who developed a retrograde dissection after endovascular stent graft placement. The emergent surgical treatment undertaken consisted of ascending aorta replacement without treating the arch in account of the presence of the endoluminal prosthesis.

Key Words: Thoracic aortic stenting • Retrograde dissection • Ascending aorta replacement

	1. Introduction

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion References

 
Endovascular stent grafting of descending thoracic aorta has recently become a valid and quite safe alternative to surgical treatment of the type B aortic dissection [1–3,6,7] even though it has been related to some complications such as graft displacement, aortic injury, paraplegia, embolization, stroke, left arm ischemia. [5]

Here we report a new and severe complication, which is the retrograde extension of the dissection up to the aortic valve throughout the arch and the ascending aorta.

	2. Clinical summary

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion References

 
A 57-year-old man with a history of hypertension was admitted to our hospital with chest pain irradiated to the back. Chest computed tomographic (CT) scan revealed a type B dissection starting immediately after the origin of the left subclavian artery and extending down to the right iliac artery.

The patient was transferred to the intensive care unit and put on B-blockers and nitrates.

Fifteen days later we performed an angiography which confirmed the previous diagnosis and under peridural anaesthesia the patient undertook insertion of the two endovascular stent grafts (via the surgically exposed left femoral artery) to exclude the intimal tear and obliterate the false lumen – THORACIC EXCLUDER (WC Gore, Flagstaff, AR) 40 mmx15 cm proximally and 37 mmx15 cm distally.

The proximal graft excluded also the origin of the left subclavian artery which was filled in a retrograde way. There were no signs and symptoms of ischemia or malperfusion of the left arm.

Angiography check showed no endovascular leak after proximal balloon dilatation, but a retrograde extension of the dissection to the arch and ascending aorta with perfusion of the false lumen not coming from the original tear which was excluded by the stents.

On the basis of these finding we decided to operate urgently on this patient. The operation was performed through a median sternotomy, cardiopulmonary bypass was instituted using a two stage cannulation for the right atrium and cannulation of the already opened left femoral artery. The circulation was stopped at 18°C, the myocardial protection was maintained with intermittent retrograde cold blood cardioplegia and retrograde perfusion of superior vena cava was undertaken during circulatory arrest.

We explored the aortic arch in which we could not find any tear and the proximal part of the endovascular graft stopped us from seeing beyond the left carotid artery. We decided then to replace just the ascending aorta with an INTERGARD graft no. 22 reinforcing the proximal and distal anastomoses with resorcine-formolo glue and two teflon felt strips and we decided not to treat the excluded left subclavian artery because of the absence of symptoms and the angiographic backflow in this vessel. The patient was extubated the day after surgery, the post-operative course was uneventful and the patient was discharged in day 20 post-op.

A CT scan done two weeks after the operation showed a perfused false lumen by an intimal tear in the distal aortic arch, but this dissection was limited to the arch by the surgical graft proximally and the endovascular graft distally.

	3. Discussion

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion References

 
Type B aortic dissection, despite the fact it is treated medically if uncomplicated, remains a high risk condition of death and in fact mortality at 1 month is 9%, at 1 year is 11%, at 5 years is 20% [8]. Endovascular stent grafting is an appealing and relatively easy procedure to decrease morbidity and mortality associated with medical and/or surgical therapy [4–7]. The timing of this treatment should consider the high risk of mortality in the first month and that is why we suggest an early endovascular procedure in the acute phase.

Many complications have been reported in literature [5], but to our knowledge nobody experienced a retrograde dissection which basically can transform a type B in a type A dissection. Unfortunately the graft itself can avoid the possibility of replacing entirely the arch, because it is too difficult and/or too dangerous to remove it.

Our first choice treatment in uncomplicated type B dissection remains early endovascular stenting despite this case. So far in our patients this remains the only major complication over 20 procedures in the last year.

	References

Top Abstract 1. Introduction 2. Clinical summary 3. Discussion References

 

1. Parodi J.D., Palmaz J.C., Barone H.D. Transfemoral intraluminal graft implantation for abdominal aortic aneurysm. Ann Vasc Surg 1991;5:491-499.[Medline]
2. Dake M.D., Miller D.C., Semba C.P., et al. Transluminal placement of endovascular stent-graft for the treatment of descending thoracic aortic aneurysm. N Engl J Med 1994;331:1729-1734.[Abstract/Free Full Text]
3. Miller D.C., Mitchell R.S., Dake M.D. Midterm results of ‘first generation‘ endovascular stent graft for descending thoracic aortic aneurysm. Proceeding of the Sixth Aortic Surgery Symposium. 1998:34-35.
4. Nienaber C.A., Fattori R., Lund G., Dieckmann C., Wolf W., von Kodolitsch Y., Nicolas V., Pierangeli A. Non-surgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999;340:1539-1545.[Abstract/Free Full Text]
5. Von Fricken K., Karamanoukian H.L., Ricci M., Taheri A., Bergsland J., Salerno T.A. Aortobronchial fistula after endovascular stent graft repair of the thoracic aorta. Ann Thorac Surg 2000;70:1407-1409.[Abstract/Free Full Text]
6. Grabenwoger M., Hutschala D., Ehrlich M.P., Cartes-Zumeldu F., Thurnher S., Lammer J., Wolner E., Havel M. Thoracic aorta aneurysm: treatment with endovascular self-expandable stent graft. Ann Thorac Surg 2000;69:441-445.[Abstract/Free Full Text]
7. Saccani S, Ugolotti U, Larini P, Marcato C, Ballore L, Beghi C, Gherli T. Endoluminal repair of aortic aneurysms. Our experience. 49th International Congress of the European Society for Cardiovascular Surgery, Dresden, June 2000.
8. Kirlin J.W., Barratt-Boyes B.G. Cardiac surgery. New York: Churchill Livingstone Inc, 1993:1726-1727.

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