Interact CardioVasc Thorac Surg 2009;8:266-268. doi:10.1510/icvts.2008.191361
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Vascular general |
Endovascular stent placement for acute type-B aortic dissection with malperfusion – an intentional surgical delay and a possible ‘bridging therapy’
Wakako Fujita,
Kazuyuki Daitoku,
Satoshi Taniguchi and
Ikuo Fukuda*
Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, 036-8562, Zaifu-cho 5, Hirosaki city, Aomori, Japan
Received 12 September 2008;
received in revised form 8 October 2008;
accepted 10 October 2008
*Corresponding author. Tel.: +81-172-39-5074; fax: +81-172-37-8340.
E-mail address: ikuofuku{at}cc.hirosaki-u.ac.jp (I. Fukuda).
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Abstract
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Acute aortic dissection frequently causes life-threatening organ ischemia. The optimal therapy for acute type-B aortic dissection is still controversial. Early surgery for acute dissections with organ malperfusion is known to carry a high morbidity and mortality. Endovascular treatment, such as stent placement for branch stenosis, percutaneous balloon fenestration for compression of the true channel and aortic stent placement to support collapsed true channel, is becoming an alternative form of treatment. However, it is not clear whether endovascular intervention alone is effective in the long term. We herein report a case of emergency percutaneous endovascular stenting with intentional surgical delay in a patient who had visceral and lower extremity malperfusion due to acute type-B dissection. A 10x57 mm bare metal stent was inserted into the obliterated true channel of the thoracoabdominal aorta 3 h after onset of symptoms. It immediately relieved the abdominal and lower limb ischemic symptoms. The advantage of small-sized stent placement is its easiness and being gentle to fragile intima. The small-sized stent placement for patients with acute aortic dissection with visceral organ ischemia may be a promising ‘bridging therapy’ before they undergo traditional central repair.
Key Words: Acute aortic dissection; Small-sized stent; Organ ischemia
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1. Introduction
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Acute aortic dissection is a life-threatening clinical entity that may cause organ ischemia during acute stage. Approximately 30% of patients with aortic dissection develop organ malperfusion and prevalence of visceral organ malperfusion is closely related with surgical mortality and morbidity, ranging from 50 to 80% [1]. We report a case of percutaneous endovascular stenting in a patient who had visceral and lower extremity malperfusion due to acute Stanford type-B dissection.
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2. Case
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A 53-year-old man was admitted to our hospital because of back pain. On admission, the blood pressure was 180/62 mmHg, and pulse rate was 78 beats per minute. Physical examination of the chest and abdomen showed no signs of visceral ischemia. Peripheral arterial pulses were well palpable in the upper and lower extremities. Laboratory data were unremarkable except for white blood cell count of 13,580/mm3 and C-reactive protein of 2.0 mg/dl. Contrast enhanced CT revealed an acute aortic dissection extending from the descending aorta to the right common iliac and the left internal iliac arteries. Intimal tear was located within the aorta just distal to the origin of the left subclavian artery. Whereas the celiac, the superior mesenteric, and the right renal arteries were supplied from the true channel, the left renal and the inferior mesenteric arteries were supplied from the false channel. Diagnosis of Stanford type-B dissection was made and the medical therapy was started. On day eight after onset, the patient suddenly complained of severe abdominal pain. Physical examination of the abdomen revealed no tenderness and normal bowel sound. However, pulsations of bilateral femoral arteries were weak. Emergent contrast enhanced CT revealed narrowing of the abdominal true channel at the level of the celiac artery compressed by the false lumen. External diameter of the descending and the abdominal aorta was the same as it was at the onset of dissection. Pleural effusion was not observed. Although enhancement of the left renal artery and the superior mesenteric artery was good, blood flow to the celiac, the right renal and bilateral common iliac arteries was decreased (Fig. 1). Diagnosis of delayed acute malperfusion of visceral organs and lower extremities was made. Immediate angiography from the right femoral artery revealed severe stenosis of the true channel at the thoracoabdominal junction but visceral branches were patent. At three hours after onset of visceral ischemia, a 10x57 mm bare metal stent (Boston Scientific Express®, Boston Scientific, Natick, USA) was inserted into the obliterated true channel of the thoracoabdominal aorta via the right femoral artery (Fig. 2). After the procedure, blood flow alleviated the abdominal symptoms and lower limb ischemia disappeared, and the patient recovered from critical condition without any complication. Anticoagulation therapy with heparin followed by warfarin was started. Follow-up CT demonstrated appropriate location of the stent and persistent flow to the celiac, the superior mesenteric and the right renal arteries. After stent implantation, the patient was discharged without complications. The antiplatelet drug was given and the patient had remained asymptomatic for visceral and lower limb ischemia for seven months after onset.
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Fig. 2. Abdominal aortogram before (a) and after (b) placement of the bare metal stent. Dilatation of the obliterated true lumen and improvement of the visceral blood flow was observed.
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3. Discussion
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The optimal therapy for acute type-B aortic dissection with visceral organ ischemia remains controversial [2–4]. There is a consensus that medical treatment is better than surgery for uncomplicated type-B dissection [2]. Emergency surgical intervention with replacement of the descending aorta is the only effective option for patients with life-threatening complications, such as rupture and impending rupture with rapid increase of aortic diameter and refractory pain [1]. However, classical graft replacement using cardiopulmonary bypass in acute phase is accompanied by high risk. As for such cases with visceral or lower extremity ischemia, mortality and morbidity will increase due to ischemia-reperfusion injury to malperfused organs and systemic effects of metabolites [5]. In this situation, duration of ischemia prior to reperfusion is a key issue to save patients. Despite radicality and proved long-term outcome, classical graft replacement takes a long time until reperfusion and has uncertainty for relief of ischemia even if the false channel would be closed. Another option is surgical fenestration of the abdominal aorta to decrease the pressure of the false channel and to relieve the compression of stenosis in true channel. Deeb and colleages [5] advocated endovascular intervention with intentional delay of surgery when organ malperfusion was present. They reported excellent outcome with mortality of 20% among 10 patients by this strategy. They employed a combination of several endovascular techniques including stent placement for branch stenosis, percutaneous balloon fenestration for compression of the true channel and aortic stent placement to support collapsed true channel. They recommended this strategy because of quick relief of ischemia and less invasiveness.
In our case, the ischemic region was so wide that whole visceral organs and lower limbs were endangered by critical ischemia. As many organs were affected, the risk of reperfusion injury was also potentially more severe. Therefore, we performed emergency percutaneous stent placement into the stenosed segment of true lumen under local anesthesia. The procedure was successful and the blood flow to compromised arteries was restored promptly. Endovascular stent grafting for occlusion of entry is more useful for the rapid relief of organ malperfusion. Although this method is also a less invasive option, consensus for stent grafting in acute phase has not been obtained. The most serious complication is damage to fragile intima and creation of new proximal entry. Also stent grafting for type-B dissection lacks long-term follow-up data. The advantage for small-sized stenting to relieve dissection related stenosis of true channel is the easiness of technique and its gentleness for the fragile intima. Disadvantage includes dislocation of the stent and thrombotic occlusion. This small-sized stent placement for patients who have acute aortic dissection with visceral organ ischemia may be a promising ‘bridging therapy’ before they undergo central repair.
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References
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Abstract
1. Introduction