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Aortic dissection originating in the suprarenal abdominal aorta
CASE REPORT
Aortic dissection originating in the suprarenal abdominal aorta Bruce M. Elliott, MD, Charles S. Roberts, MD, Jacob G. Robison, MD, and Thomas E. Brothers, MD, Charleston) S. C. Spontaneous dissection of the abdominal aorta originating from the suprarenal aorta is very rare. Previous reports attest to the lethal nature of this disorder. This case represents the first report of successful repair of a spontaneous suprarenal abdominal aortic dissection by graft insertion with obliteration of both the entrance tear and the false lumen with reimplantation of the visceral vessels. (J VAse SURG 1994;19:1092-6.)
Spontaneous dissection of the aorta most commonly originates in the ascending aorta (70%), followed by the descending thoracic aorta (22%), the transverse aorta (7%), and rarely, the abdominal aorta (1 % ).1 When the dissection originates in the abdominal aorta, it is typically in the infrarenal aorta. 2 Operative management of aortic dissection originating from the suprarenal abdominal aorta has been reported to be associated with dismal perioperative mortality. 2-8 We believe this represents the first report of a successful repair of spontaneous suprarenal aortic dissection with prosthetic replacement of the entire abdominal aorta obliterating the originating tear and false lumen with reimplantation of the visceral vessels. CASE REPORT A 69-year-old man with hypertension was admitted with a 3-week history of intermittent postprandial epigastric abdominal pain. The patient denied any trauma, back pain, hematuria, or lower extremity claudication. His chronic hypertension was controlled on two medications. There was a vague history of occasional exertional angina and a remote history of prior appendectomy and reduction of a colonic volvulus. At the time of presentation his blood pressure was 160/85 mm Hg, and a nontender abdominal aortic aneurysm was palpable. Laboratory test results were normal, including a serum creatinine of 1.3 mg/d!. From the Section of Vascular Surgery, Department of Surgery, Medical University of South Carolina, Charleston. Reprint requests: Bruce M. Elliott, MD, Section of Vascular Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC 29425. Copyright © 1994 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter. 0741-5214/94/$3.00 + 0 24/4/52466
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Ultrasonography demonstrated a 7 cm---diameter abdominal aortic aneurysm with ill-defined proximal and distal extension. Computed tomography of the abdomen (Figs. 1 and 2) demonstrated two lumina within the abdominal aorta extending from the level of the diaphragm proximally into the right common iliac artery distally without evidence of rupture. The celiac, superior mesenteric, and left renal arteries originated from the left lumen. The origin of the right renal artery was not clearly identified; however, both kidneys demonstrated symmetrical contrast enhancement and size. Aortography (Figs. 3 and 4) confirmed the presence of an abdominal aortic dissection and aneurysm. The entrance tear originated at the level of the celiac artery on the posterior wall of the aorta, with retrograde dissection to the level of the diaphragm and distal extension into the right common iliac artery. The patient underwent transabdominal exploration through a midline incision, with medial rotation of the abdominal viscera from left to right to expose the entire length of the abdominal aorta and its visceral branches. Division of the left crus of the diaphragm permitted access to the uninvolved descending thoracic aorta, obviating the need for formal thoracotomy. Mter clamp occlusion proximally and distally, the abdominal aortic aneurysm was incised throughout its full length. A 2 cm entrance tear was identified in the posterior wall of the aorta at the level of the celiac axis. The septum was excised proximally for the extent of the dissection, and a 24 mm woven Dacron graft was anastomosed end-to-end to the normal descending thoracic aorta. Poor quality of the celiac artery as a result of inflammation from the subacute dissection precluded its reimplantation and required ligation. The superior mesenteric artery, a replaced hepatic artery, and the right renal artery were all reimplanted as a single Carrel patch. The left renal artery was reimplanted separately. The graft was anastomosed distally to the bifurcation of the aorta obliterating the false lumen in the right common iliac
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Fig. 1. Computed tomogram of suprarenal aorta at level of entrance tear. True and false channels communicate.
Fig. 2. Computed tomogram of aorta at level of superior mesenteric artery, which arises from true lumen on left.
artery. Adequate visceral and lower extremity arterial flow was assured with continuous-wave Doppler scanning at the completion of the procedure. The patient's postoperative course was relatively uneventful, with the exception of transient atrial fibrillation. Postoperative aortography confirmed the complete obliteration of the dissection with patent reconstructions of the reimplanted visceral vessels and the celiac axis from the replaced hepatic artery (Figs. 5 and 6). The patient remains well and free of complications 1 year after his operation.
DISCUSSION Spontaneous dissection of the aorta originating from the abdominal aorta is rare. Single institutional series demonstrate the frequency of an abdominal origin to be between 1 and 2% of all aortic dissections. 1,9-12 Spontaneous dissection originating from the suprarenal abdominal aorta has been described a total of 15 times in the English literature, with half of these undergoing operative intervention (Table I). As opposed to thoracic aortic dissections
JOURNAL OF VASCULAR SURGERY Junc 1994
1094 Elliott et al.
Fig. 3. Lateral aortogram reveals large false channel with its most superior point at level of aortic hiatus.
Fig. 4. Anterior aortogram with left renal artery originating from true lumen. Right-sided blush of contrast represents aortic false lumen.
Table I. Reported patients with suprarenal aortic dissection who underwent operation Author
Year
Age
Sex
DeAngelis 3 Amer4 Davids Bradbrook6 Sniderman 7 Crawford 12 Arendrut Graham Elliott
1943 1962 1970 1974 1978 1982 1983 1988 1993
64 57 54 46 66 60 43 56 69
M M F M M M F F M
Duration of symptoms
3 yr 1 day <1 day <1 day < 1 day Chronic <1 day <1 day 3 weeks
Rupture
Operation
Yes No No No No Contained Yes No No
Laparotomy Reentry procedure Colectomy Reentry procedure Ascending aortic graft Dacron patch Laparatomy Colectomy, AFB Graft insertion visceral reimplantation
Survival (days)
1 0 2 > 1 yr 0 >30 days 0 6 > 1 yr
APB, Aortofemoral bypass.
where back pain is typical, the symptoms associated with abdominal aortic dissections are nonspecific. In a review of the 47 reported cases of abdominal aortic dissection, approximately 33% presented with lower extremity ischemia and 30% with abdominal pain. Only 20% were admitted with back or flank pain. 2 Only two patients survived operation; one following a fenestration procedure,6 the other following a patch closure of the entrance tear. 12 The only previous report of graft insertion resulted in a perioperative death as a result of the fact that the ascending aorta was mistakenly considered to be the site of origin, whereas the true site of origin in the suprarenal
abdominal aorta was not discovered until autopsy? Three of seven patients treated without operation survived the acute dissection, with two survivals reported at 30 months and 4 years, respectively?,13.18 Little qata are available comparing operative and nonoperative therapy for spontaneous aortic dissection originating in the suprarenal abdominal aorta. The major complications associated with nonoperative management of a spontaneous abdominal aortic dissection result in significant mortality rates from either rupture or acute visceral ischemia. Complete obliteration of the entrance site and its false channel by graft replacement of the aorta and visceral
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Fig. 6. Postoperative anterior aortogram demonstrates patency of reimplanted left renal artery, SMA, and right renal artery. Note prompt collateral filling of celiac access via collateral vessels.
Fig. 5. Postoperative aortogram with arraws indicating proximal and distal graft anastomoses.
reimplantation is a viable alternative, particularly with an associated aneurysm.
REFERENCES 1. Roberts CS, Roberts We. Aortic dissection with the entrance tear in abdominal aorta. Am Heart J 1991;121:1834-5. 2. Graham D, Alexander J1, Franceschi D, Rashad F. The management oflocalized abdominal aortic dissections. J VAse SURG 1988;8:582-91. 3. DeAngelis E. Dissecting aneurysm of the abdominal aorta. Am Heart J 1943;26:124-8.
4. Amer NC, Schaeffer HC, Dominto RT, Sawyer PN, Wesolowski SA. Aortic dissection presenting as iliac artery occlusion. N Engl J Med 1962;266:1040-2. 5. David D, Blumenberg RM. Subintimal aortic dissection with occlusion after blunt abdominal trauma. Arch Surg 1970; 100: 302-4. 6. Bradbrook RA, Marshall AJ, Spreadbury PL. Hypertension with dissecting abdominal aortic aneurysm. Br Med J 1974; 4:23-4. 7. Sniderman KW, Sos TA, Gay WA, Subramanian VA. Aortic dissection beginning in the abdomen. Am J Roentgenol 1978;130:115-8. 8. Arendrup H, Frimodt-Moeller PC, Christensen JEJ. Acute dissection confined to the abdominal aorta. Scand J Thorac Cardiovasc Surg 1983;17:121-3. 9. Gore I, Seiwert VJ. Dissecting aneurysm of the aortapathologic aspects: an analysis of eight-five fatal cases. Arch Path 1952;53:121-41. 10. Hirst AE Jr, Johns VJ Jr, Kime SW Jr. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine 1958;37: 217-79. 11. Shennan T. Dissecting aneurysms. (Series no. 193) London: Medical Research Council, His Majesty's Stationary, 1934: 138 pages. Special report. 12. Crawford ES, Crawford JL. Aortic dissection and dissecting aortic aneurysms. In: Crawford ES, ed. Diseases of the Aorta. Baltimore: Williams and Wilkins, 1984:168214. 13. Wood FC, Pendergrass EC, Ostrum HW. Dissecting aneurysm of the aorta with special reference to its roentgenographic features. Am J Roentgenol 1932;28: 437-65.
1096 Elliott et al.
14. Buckley TI. Hematuria associated with dissecting aneurysms of the abdominal aorta. J UroI1941;44:816-20. 15. Wallwork DW. Survival of four years following dissecting aneurysm of the abdominal aorta. N Engl J Med 1943;228: 451-2. 16. Bauersfield SR. Dissecting aneurysm of the aorta: a presentation of fifteen cases and a review of the recent literature. Ann lot Med 1947;26:873-9. 17. Puderback WJ. Dissecting aneurysm of the aorta and its
JOURNAL OF VASCULAR SURGERY June 1994
relation to the acute condition of the abdomen. Am J Surg 1954;87:887-90. 18. VanMaele RG, Bok LD, Schil PEV, et al. Limited acute dissection of the abdominal aorta: report of five cases. J Cardiovasc Surg 1992;33:298-304.
Submitted June 23, 1993; accepted Oct. 26, 1993.
Aortic dissection originating in the suprarenal abdominal aorta Bruce M. Elliott, MD, Charles S. Roberts, MD, Jacob G. Robison, MD, and Thomas E. Brothers, MD, Charleston) S. C. Spontaneous dissection of the abdominal aorta originating from the suprarenal aorta is very rare. Previous reports attest to the lethal nature of this disorder. This case represents the first report of successful repair of a spontaneous suprarenal abdominal aortic dissection by graft insertion with obliteration of both the entrance tear and the false lumen with reimplantation of the visceral vessels. (J VAse SURG 1994;19:1092-6.)
Spontaneous dissection of the aorta most commonly originates in the ascending aorta (70%), followed by the descending thoracic aorta (22%), the transverse aorta (7%), and rarely, the abdominal aorta (1 % ).1 When the dissection originates in the abdominal aorta, it is typically in the infrarenal aorta. 2 Operative management of aortic dissection originating from the suprarenal abdominal aorta has been reported to be associated with dismal perioperative mortality. 2-8 We believe this represents the first report of a successful repair of spontaneous suprarenal aortic dissection with prosthetic replacement of the entire abdominal aorta obliterating the originating tear and false lumen with reimplantation of the visceral vessels. CASE REPORT A 69-year-old man with hypertension was admitted with a 3-week history of intermittent postprandial epigastric abdominal pain. The patient denied any trauma, back pain, hematuria, or lower extremity claudication. His chronic hypertension was controlled on two medications. There was a vague history of occasional exertional angina and a remote history of prior appendectomy and reduction of a colonic volvulus. At the time of presentation his blood pressure was 160/85 mm Hg, and a nontender abdominal aortic aneurysm was palpable. Laboratory test results were normal, including a serum creatinine of 1.3 mg/d!. From the Section of Vascular Surgery, Department of Surgery, Medical University of South Carolina, Charleston. Reprint requests: Bruce M. Elliott, MD, Section of Vascular Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC 29425. Copyright © 1994 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter. 0741-5214/94/$3.00 + 0 24/4/52466
1092
Ultrasonography demonstrated a 7 cm---diameter abdominal aortic aneurysm with ill-defined proximal and distal extension. Computed tomography of the abdomen (Figs. 1 and 2) demonstrated two lumina within the abdominal aorta extending from the level of the diaphragm proximally into the right common iliac artery distally without evidence of rupture. The celiac, superior mesenteric, and left renal arteries originated from the left lumen. The origin of the right renal artery was not clearly identified; however, both kidneys demonstrated symmetrical contrast enhancement and size. Aortography (Figs. 3 and 4) confirmed the presence of an abdominal aortic dissection and aneurysm. The entrance tear originated at the level of the celiac artery on the posterior wall of the aorta, with retrograde dissection to the level of the diaphragm and distal extension into the right common iliac artery. The patient underwent transabdominal exploration through a midline incision, with medial rotation of the abdominal viscera from left to right to expose the entire length of the abdominal aorta and its visceral branches. Division of the left crus of the diaphragm permitted access to the uninvolved descending thoracic aorta, obviating the need for formal thoracotomy. Mter clamp occlusion proximally and distally, the abdominal aortic aneurysm was incised throughout its full length. A 2 cm entrance tear was identified in the posterior wall of the aorta at the level of the celiac axis. The septum was excised proximally for the extent of the dissection, and a 24 mm woven Dacron graft was anastomosed end-to-end to the normal descending thoracic aorta. Poor quality of the celiac artery as a result of inflammation from the subacute dissection precluded its reimplantation and required ligation. The superior mesenteric artery, a replaced hepatic artery, and the right renal artery were all reimplanted as a single Carrel patch. The left renal artery was reimplanted separately. The graft was anastomosed distally to the bifurcation of the aorta obliterating the false lumen in the right common iliac
JOURNAL OF VASCULAR SURGERY Volume 19, Number 6
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Fig. 1. Computed tomogram of suprarenal aorta at level of entrance tear. True and false channels communicate.
Fig. 2. Computed tomogram of aorta at level of superior mesenteric artery, which arises from true lumen on left.
artery. Adequate visceral and lower extremity arterial flow was assured with continuous-wave Doppler scanning at the completion of the procedure. The patient's postoperative course was relatively uneventful, with the exception of transient atrial fibrillation. Postoperative aortography confirmed the complete obliteration of the dissection with patent reconstructions of the reimplanted visceral vessels and the celiac axis from the replaced hepatic artery (Figs. 5 and 6). The patient remains well and free of complications 1 year after his operation.
DISCUSSION Spontaneous dissection of the aorta originating from the abdominal aorta is rare. Single institutional series demonstrate the frequency of an abdominal origin to be between 1 and 2% of all aortic dissections. 1,9-12 Spontaneous dissection originating from the suprarenal abdominal aorta has been described a total of 15 times in the English literature, with half of these undergoing operative intervention (Table I). As opposed to thoracic aortic dissections
JOURNAL OF VASCULAR SURGERY Junc 1994
1094 Elliott et al.
Fig. 3. Lateral aortogram reveals large false channel with its most superior point at level of aortic hiatus.
Fig. 4. Anterior aortogram with left renal artery originating from true lumen. Right-sided blush of contrast represents aortic false lumen.
Table I. Reported patients with suprarenal aortic dissection who underwent operation Author
Year
Age
Sex
DeAngelis 3 Amer4 Davids Bradbrook6 Sniderman 7 Crawford 12 Arendrut Graham Elliott
1943 1962 1970 1974 1978 1982 1983 1988 1993
64 57 54 46 66 60 43 56 69
M M F M M M F F M
Duration of symptoms
3 yr 1 day <1 day <1 day < 1 day Chronic <1 day <1 day 3 weeks
Rupture
Operation
Yes No No No No Contained Yes No No
Laparotomy Reentry procedure Colectomy Reentry procedure Ascending aortic graft Dacron patch Laparatomy Colectomy, AFB Graft insertion visceral reimplantation
Survival (days)
1 0 2 > 1 yr 0 >30 days 0 6 > 1 yr
APB, Aortofemoral bypass.
where back pain is typical, the symptoms associated with abdominal aortic dissections are nonspecific. In a review of the 47 reported cases of abdominal aortic dissection, approximately 33% presented with lower extremity ischemia and 30% with abdominal pain. Only 20% were admitted with back or flank pain. 2 Only two patients survived operation; one following a fenestration procedure,6 the other following a patch closure of the entrance tear. 12 The only previous report of graft insertion resulted in a perioperative death as a result of the fact that the ascending aorta was mistakenly considered to be the site of origin, whereas the true site of origin in the suprarenal
abdominal aorta was not discovered until autopsy? Three of seven patients treated without operation survived the acute dissection, with two survivals reported at 30 months and 4 years, respectively?,13.18 Little qata are available comparing operative and nonoperative therapy for spontaneous aortic dissection originating in the suprarenal abdominal aorta. The major complications associated with nonoperative management of a spontaneous abdominal aortic dissection result in significant mortality rates from either rupture or acute visceral ischemia. Complete obliteration of the entrance site and its false channel by graft replacement of the aorta and visceral
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Fig. 6. Postoperative anterior aortogram demonstrates patency of reimplanted left renal artery, SMA, and right renal artery. Note prompt collateral filling of celiac access via collateral vessels.
Fig. 5. Postoperative aortogram with arraws indicating proximal and distal graft anastomoses.
reimplantation is a viable alternative, particularly with an associated aneurysm.
REFERENCES 1. Roberts CS, Roberts We. Aortic dissection with the entrance tear in abdominal aorta. Am Heart J 1991;121:1834-5. 2. Graham D, Alexander J1, Franceschi D, Rashad F. The management oflocalized abdominal aortic dissections. J VAse SURG 1988;8:582-91. 3. DeAngelis E. Dissecting aneurysm of the abdominal aorta. Am Heart J 1943;26:124-8.
4. Amer NC, Schaeffer HC, Dominto RT, Sawyer PN, Wesolowski SA. Aortic dissection presenting as iliac artery occlusion. N Engl J Med 1962;266:1040-2. 5. David D, Blumenberg RM. Subintimal aortic dissection with occlusion after blunt abdominal trauma. Arch Surg 1970; 100: 302-4. 6. Bradbrook RA, Marshall AJ, Spreadbury PL. Hypertension with dissecting abdominal aortic aneurysm. Br Med J 1974; 4:23-4. 7. Sniderman KW, Sos TA, Gay WA, Subramanian VA. Aortic dissection beginning in the abdomen. Am J Roentgenol 1978;130:115-8. 8. Arendrup H, Frimodt-Moeller PC, Christensen JEJ. Acute dissection confined to the abdominal aorta. Scand J Thorac Cardiovasc Surg 1983;17:121-3. 9. Gore I, Seiwert VJ. Dissecting aneurysm of the aortapathologic aspects: an analysis of eight-five fatal cases. Arch Path 1952;53:121-41. 10. Hirst AE Jr, Johns VJ Jr, Kime SW Jr. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine 1958;37: 217-79. 11. Shennan T. Dissecting aneurysms. (Series no. 193) London: Medical Research Council, His Majesty's Stationary, 1934: 138 pages. Special report. 12. Crawford ES, Crawford JL. Aortic dissection and dissecting aortic aneurysms. In: Crawford ES, ed. Diseases of the Aorta. Baltimore: Williams and Wilkins, 1984:168214. 13. Wood FC, Pendergrass EC, Ostrum HW. Dissecting aneurysm of the aorta with special reference to its roentgenographic features. Am J Roentgenol 1932;28: 437-65.
1096 Elliott et al.
14. Buckley TI. Hematuria associated with dissecting aneurysms of the abdominal aorta. J UroI1941;44:816-20. 15. Wallwork DW. Survival of four years following dissecting aneurysm of the abdominal aorta. N Engl J Med 1943;228: 451-2. 16. Bauersfield SR. Dissecting aneurysm of the aorta: a presentation of fifteen cases and a review of the recent literature. Ann lot Med 1947;26:873-9. 17. Puderback WJ. Dissecting aneurysm of the aorta and its
JOURNAL OF VASCULAR SURGERY June 1994
relation to the acute condition of the abdomen. Am J Surg 1954;87:887-90. 18. VanMaele RG, Bok LD, Schil PEV, et al. Limited acute dissection of the abdominal aorta: report of five cases. J Cardiovasc Surg 1992;33:298-304.
Submitted June 23, 1993; accepted Oct. 26, 1993.