Eur J Cardiothorac Surg 2004;26:857-859
© 2004 Elsevier Science NL
Endoluminal and surgical treatment for the management of Stanford Type A aortic dissection
Hongkun Zhang*,
Ming Li,
Wei Jin,
Zhongao Wang
Department of Vascular Surgery, The First Affiliated Hospital of Medical Science, Zhejiang University, No. 79 Qing Chun road, HangZhou 310003, China
Received 13 April 2004;
received in revised form 21 June 2004;
accepted 1 July 2004.
* Corresponding author. Tel.: +86-571-8723-6847; fax: +86-571-8723-6722. (E-mail: doczhk{at}yahoo.com.cn).
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Abstract
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Stanford Type A aortic dissection is a life-threatening disease. A 46-year-old female patient with Stanford Type A aortic dissection was successfully treated by placing a stent-graft into the ascending aorta via femoral artery. No complication was found immediately after the operation. Bentall operation was performed to treat the development of severe aortic insufficiency 21 months after the stent-grafting procedure. Literature review was done to discuss the possibility of using endoluminal stent placement to treat Stanford Type A aortic dissection.
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1. Case report
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On January 4, 2001, a 46-year-old woman was admitted via emergency room due to acute onset of severe chest pain for 4h. Duplex Ultrasonography indicated the diagnosis of Stanford Type A aortic dissection. Magnetic resonance angiography and digital subtraction angiography (DSA) were performed to confirm the diagnosis. The ascending and descending aorta were severely compressed by the false lumen causing a significant stenosis of the aorta. An entry tear was found in the ascending aorta, aortic arch and descending aorta respectively (Fig. 1). The patient strongly opposed an open surgery and preferred medical treatment. Unfortunately, during the 2-week medical treatment, the patient was attacked by two episodes of myocardiac infarction. Instead of receiving an open surgery, the patient chose to try on endoluminal stent-grafting placement despite of the fact that there was no literature report of a successful case. The proposal of the procedure for the patient was approved by the hospital medical affair committee. The consent was signed by patient. Thus, almost two weeks after her admission, on January 22, 2001, the patient underwent the endoluminal stent-graft placement. The procedure was performed with the patient under epidural anesthesia. The stent-graft (it is made from silk supported by a series of stainless steel Gianturco Z-stent, 38x70mm2) with an introducer (Cook, Australia) was advanced to the entry tear in the ascending aorta via right external iliac artery. The stent-graft was deployed to close the entry tears. Aortagraphy was performed immediately after deployment to confirm the complete closure of the entry tears in the ascending aorta, aortic arch and descending aorta. The strictrued ascending and descending aorta was completely dialated. The aortic dissection disappeared (Fig. 2). The original plan of an additional stent-graft placement in descending aorta was cancelled. Postoperative Duplux Ultrasonography showed the thrombosis of the false lumen in aortic arch and descending aorta. The patient was discharged without any significant complaints.
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Fig. 1. Digital subtraction angiography of aorta proved the diagnosis of Stanford Type A aortic dissection.
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Postoperative follow-up found that her general condition remained normal for one year. But one year later, the patient developed a progressive chest distress and shortness of breathing. Duplux Ultrasonography upon readmission revealed the cardiomegaly, severe aortic valve insufficiency and sever impaired left heart contracibility (LVEF <30%). On October 28th, 2002, the patient underwent a Bentall operation under deep hypothermic circulatory arrest state. The ascending aorta was incised vertically, The stent was removed along with the resection of the aortic valvular leaflet. Then a No. 25 carbomedics valvular prosthesis was replaced and anastomosed with left and right coronaries. The wall of aneurysm was sutured around the prosthesis. The postoperative convalescence was uneventful. Postoperative Duplex Ultrasonography showed aortic valve was functioning well. The patient was discharged 2 weeks after the surgery. No complaints had been made on regular follow-up.
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2. Discussion
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Aortic dissection is the most life-threatening disease in cardiovascular surgery, especially when the entry tear is situated in the ascending aorta (Stanford Type A). The treatment for Stanford Type A aortic dissection is more difficult. The traditional procedure for the treatment of aortic dissection is to resect the entry tear in the ascending aorta and replace the prosthesis under the deep hypothermic circulatory arrest state. Many times, the replacement of aortic valve is required. Although the surgical techniques are continuously improving, the high operative mortality rate (10–20%) remained a great challenge for the cardiothoracic surgeons.
Someone has reported the successful treatment of the Stanford Type A aortic dissection with the entry tear in the descending aorta [1]. But in most of cases with Stanford Type A aortic dissection, the entry tears are sited in the ascending aorta. The question was whether we could treat these patients with endoluminal stent-grafting replacement. Literature reviews revealed no single successful case that has been reported in the past [2,3]. In order to prevent occlusion of the coronary artery and innominate artery, it was important to mark the site of entry tear accurately, and determine an adequate length of the stent before deployment. The stent-graft must be deployed swiftly. Otherwise, the stent will block the blood flow and cause temporary cerebral ischemia or even Aolam-Stak attack. During the stent deployment, the patient had a transient loss of consciousness. The whole procedure lasted 100min with a minimal trauma, no evident postoperative complication. Complete thrombosis was found in the false lumen in both ascending and descending aorta. As comparing our procedure with a traditional one, the advantages of this procedure are that the hypothermic circulatory arrest was not required, and the complete blockage of the false lumen in the descending aorta was achieved. Unfortunately, the patient developed aortic valve insufficiency 21 months after the stent-grafting placement. A replacement of ascending aorta and aortic valve was performed. The dissection of ascending and descending aorta was closed. Was it possible that the aortic valve insufficiency was induced by the stent-graft? The selection of stent should have no question as we had carefully measured the diameter of the ascending aorta which was 33mm and implanted a stent with the diameter of 38mm. There was no definite answer in literature about whether a stent could be implanted in the ascending aorta or what kind of stent should be used and what complication should be expected. Aortic valve insufficiency in this patient was the outcome of the disease progression or an intrinsic complication of the stent-graft replacement? However, the cause of the aortic valve insufficiency in this case remained uncertain and deserved further investigation. A long-term follow-up and accumulation of cases are to be planned for a further study. It should be noted that once the complication arises, the treatment could be more troublesome. Thus the treatment for Stanford Type A aorta dissection with ascending aortic stent-grafting placement should be applied cautiously.
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References
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- Kato N, Shimono T, Hirano T, Ishida M, Yada I, Takeda K. Transluminal placement of endovascular stent-grafts for the treatment of type A aortic dissection with an entry tear in the descending thoracic aorta. J Vasc Surg 2001;34(6):1023-1028.[CrossRef][Medline]
- Kato M, Kuratani T, Kaneko M, Kyo S, Ohnishi K. The results of total arch graft implantation with open stent-graft placement for type A aortic dissection. J Thorac Cardiovasc Surg 2002;124(3):531-540.[Abstract/Free Full Text]
- Mizuno T, Toyama M, Tabuchi N, Wu H, Sunamori M. Stented elephant trunk procedure combined with ascending aorta and arch replacement for acute type A aortic dissection. Eur J Cardiothorac Surg 2002;22(4):504-509.[Abstract/Free Full Text]
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Abstract
1. Case report
