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Deployment of Endograft in the Ascending Aorta to Reverse Type A Aortic Dissection
Deploy#final 31/3/03
Case Report
Deployment of Endograft in the Ascending Aorta to Reverse Type A Aortic Dissection Wang Zhong Gao, Carlo G. Massimo,1 Li Ming, Pan Song Ling, Zhang Hong Kun, Jing Wei, Zhao Hai Ge, Chen Xu Dong and Chen Hong, Vascular Institute, First Affiliate Hospital, College of Medicine, Zhejiang University, Hangzhou, China, and 1INSACOR Instituto Salvadoreno del Corazon, San Salvador, El Salvador.
Current surgery to treat acute type A aortic dissection involving an intimal tear in the ascending aorta consists of resection and replacement, but mortality is high. We report the case of a 46-year-old female patient with Marfan syndrome who presented with excruciating retrosternal pain and breathing distress after a bowel movement with stress. Magnetic resonance imaging and multicolour sonography showed type A aortic dissection extending from the aortic root to the right iliac artery, with intimal tears in the ascending aorta above the sinotubular junction, the distal arch beyond the left subclavian artery and the isthmic region. We adapted the endoluminal stenting technique to this case of type A aortic dissection by sealing the intimal tears in the ascending aorta using endovascular introduction of one endoluminal graft, as confirmed on angiography. The patient was discharged after 10 days. Follow-up examination by computed tomography after more than 1 year revealed no sign of dissection at any level of the aorta. [Asian J Surg 2003;26(2):117–9]
Introduction
Case report
Cardiovascular surgeons agree that acute type A aortic dissection must be treated as soon as possible.1 When the intimal tear is located in the ascending aorta, the current surgical technique consists of resecting and replacing the ascending aorta containing the intimal tear. If aortic valve regurgitation is also present, additional procedures may be requested for preserving or replacing the valve. Despite the improvements in anaesthesiological–surgical technique, and the introduction of aids such as biological glue, mortality is still high2 and the disease is not curable. The persistence of the distal false lumen represents the main cause of late deaths.3 With the advent of the endoluminal stenting technique, we have developed the possibility of treating acute type A dissection by sealing the intimal tear in the ascending aorta with an endoluminal graft introduced by the endovascular technique. Here, we report a successfully treated patient with more than a year of follow-up.
A 46-year old woman with Marfan syndrome was admitted as an emergency on January 9, 2001. The patient presented with excruciating retrosternal pain and breathing distress after a bowel movement with stress. Her blood pressure was 171/99 mmHg. Magnetic resonance imaging (MRI) and multicolour sonography showed type A aortic dissection extending from the aortic root to the right iliac artery. One intimal tear was detected in the ascending aorta above the sinotubular junction, a second one in the distal arch beyond the left subclavian artery, and a third in the isthmic region. Angiography showed that the true lumen in the ascending aorta was reduced to a tiny channel extending from the ascending aorta all the way to the bifurcation (Figure, A–C) due to compression and squeezing by the dilated and fully separated false lumen. The false lumen extended along the arch and bulged beyond the left subclavian artery, where the other two intimal lacerations were observed. The dilated false lumen accounted for a widened cardiovascular image on
Address correspondence and reprint requests to Dr. Wang Zhong Gao, Vascular Institute, First Affiliate Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310002, China. E-mail: [email protected] • Date of acceptance: 8th October, 2002 © 2003 Elsevier. All rights reserved.
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■ WANG AND OTHERS ■
standard chest X-ray. No signs of aortic valve regurgitation were present. After admission, she had repeated cardiac angina with ST segment elevation on electrocardiography. The severe pain could not be controlled effectively with the opium receptor activator, Tramadol. Endovascular treatment was devised according to the measurements obtained from MRI and sonography. Two endografts were prepared with a silk-covered stainless steel Zstent, which had been approved for clinical trial by the China Drug Administration. A diameter of 38 mm and length of 70 mm were chosen. Then one designated endograft was placed in the ascending and proximal descending aorta in order to close all intimal tears. The operation was performed on January 22, 2001. Via a left iliac approach, an F24 delivery system loaded with one endograft at its tip was introduced into the distal left external iliac artery. Difficulties were encountered in passing the two 90˚ curves along the distal and proximal aortic arches. When the sinotubular junction was ultimately reached, the tip of the endograft was found to be clearly located beyond the intimal tear of the ascending aorta. The process of endograft
A
C
118
deployment was very difficult, but was made from the aortic sinuses to the innominate artery. However, the patient had a severe transient ischaemic attack (TIA), including loss of consciousness, seizure and ptyalism, which lasted for about 1 minute, interrupting the endograft procedure. As rescue work was performed by the anaesthetist, the endograft was fully delivered and expanded quickly. As soon as it was finished, the patient recovered from TIA. Two minutes later, angiography showed sealing of the the intimal tears and disappearance of the false lumen. The normal diameter of the entire aorta was restored (Figure, D); thus, the second graft was no longer necessary. The patient was discharged after 10 days. She had high fever for 3 days and unusual cough for 2 weeks later after deployment of the endograft, the latter perhaps related to a stimulation of the right bronchus by the large endograft. One month after discharge until the date of this report, after more than 1 year of follow-up, she had resumed light labour of working as a clerk, without discomfort. Follow-up examination by computed tomography revealed no sign of dissection at any level of the aorta.
B
D
Figure. Angiography of the patient on admission (A–C) showing the intimal tear visible in the ascending aorta, with the false lumen, under tension, squeezing the true lumen to a tiny channel (A). The dissection proceeds along the arch, bulging beyond the left subclavian artery. As the contrast medium spreads further, more squeezing of the aorta likely to jeopardize the coronary perfusion can be seen (B). The dissection continues along the descending aorta, squeezing the true lumen into a tiny lumen (C). D) After deployment of the endograft in the ascending aorta, the intimal tear is closed, the false lumen has disappeared along the entire extent of the vessel, and the true lumen has resumed its normal diameter.
ASIAN JOURNAL OF SURGERY VOL 26 • NO 2 • APRIL 2003
02002
■ ENDOGRAFT TO REVERSE TYPE A AORTIC DISSECTION ■
Discussion This is the first reported case of a patient with acute type A dissection for which a stent graft was successfully deployed into the ascending aorta using the endoluminal technique, sealing multiple intimal tears and repairing the dissection all along the vessel. This procedure may be considered for the treatment of acute type A dissection when the intimal tear is located in the ascending aorta. Thus, the spectrum of high-risk open surgical operations can be averted. Total disappearance of the false lumen leads one to think of a possible healed dissection because the early re-assemblage of the aortic wall could preserve the elastic layer. This occurrence is certainly responsible for the 20% survival rate 20 years after surgery.3 By contrast, patency of the distal false lumen after surgery foretells late pathology and eventual death. We questioned whether total aortic replacement was the treatment of choice for type A aortic dissection.4 However, in light of the results
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ASIAN JOURNAL OF SURGERY VOL 26 • NO 2 • APRIL 2003
02002
obtained with the present case, the concept of total replacement should be postponed until the evolving endovascular technique can be performed endoluminally.5
References 1. Ehrlich MP, Ergin MA, McCullough JN, et al. Results of immediate surgical treatment of all acute type A dissections. Circulation 2000; 102(Suppl 3):III248–52. 2. Kawahito K, Adachi H, Yamaguchi A, Ino T. Early and late surgical outcomes of acute type A aortic dissection in patients aged 75 years and older. Ann Thorac Surg 2000;70:1455–9. 3. Barron DJ, Livesey SA, Brown IW, et al. Twenty-year follow-up of acute type A dissection: the incidence and extent of distal aortic disease using magnetic resonance imaging. J Card Surg 1997;12:147–59. 4. Massimo CG, Presenti LF, Favi PP, et al. Simultaneous total aortic replacement from valve to bifurcation: experience with 21 cases. Ann Thorac Surg 1993;56:1110–6. 5. Massimo CG, Wang ZG, Cruz EAG, et al. Endoluminal replacement of the entire aorta for acute type A aortic dissection in a patient with Marfan syndrome. J Thorac Cardiovasc Surg 2000;120:818–20.
119
Case Report
Deployment of Endograft in the Ascending Aorta to Reverse Type A Aortic Dissection Wang Zhong Gao, Carlo G. Massimo,1 Li Ming, Pan Song Ling, Zhang Hong Kun, Jing Wei, Zhao Hai Ge, Chen Xu Dong and Chen Hong, Vascular Institute, First Affiliate Hospital, College of Medicine, Zhejiang University, Hangzhou, China, and 1INSACOR Instituto Salvadoreno del Corazon, San Salvador, El Salvador.
Current surgery to treat acute type A aortic dissection involving an intimal tear in the ascending aorta consists of resection and replacement, but mortality is high. We report the case of a 46-year-old female patient with Marfan syndrome who presented with excruciating retrosternal pain and breathing distress after a bowel movement with stress. Magnetic resonance imaging and multicolour sonography showed type A aortic dissection extending from the aortic root to the right iliac artery, with intimal tears in the ascending aorta above the sinotubular junction, the distal arch beyond the left subclavian artery and the isthmic region. We adapted the endoluminal stenting technique to this case of type A aortic dissection by sealing the intimal tears in the ascending aorta using endovascular introduction of one endoluminal graft, as confirmed on angiography. The patient was discharged after 10 days. Follow-up examination by computed tomography after more than 1 year revealed no sign of dissection at any level of the aorta. [Asian J Surg 2003;26(2):117–9]
Introduction
Case report
Cardiovascular surgeons agree that acute type A aortic dissection must be treated as soon as possible.1 When the intimal tear is located in the ascending aorta, the current surgical technique consists of resecting and replacing the ascending aorta containing the intimal tear. If aortic valve regurgitation is also present, additional procedures may be requested for preserving or replacing the valve. Despite the improvements in anaesthesiological–surgical technique, and the introduction of aids such as biological glue, mortality is still high2 and the disease is not curable. The persistence of the distal false lumen represents the main cause of late deaths.3 With the advent of the endoluminal stenting technique, we have developed the possibility of treating acute type A dissection by sealing the intimal tear in the ascending aorta with an endoluminal graft introduced by the endovascular technique. Here, we report a successfully treated patient with more than a year of follow-up.
A 46-year old woman with Marfan syndrome was admitted as an emergency on January 9, 2001. The patient presented with excruciating retrosternal pain and breathing distress after a bowel movement with stress. Her blood pressure was 171/99 mmHg. Magnetic resonance imaging (MRI) and multicolour sonography showed type A aortic dissection extending from the aortic root to the right iliac artery. One intimal tear was detected in the ascending aorta above the sinotubular junction, a second one in the distal arch beyond the left subclavian artery, and a third in the isthmic region. Angiography showed that the true lumen in the ascending aorta was reduced to a tiny channel extending from the ascending aorta all the way to the bifurcation (Figure, A–C) due to compression and squeezing by the dilated and fully separated false lumen. The false lumen extended along the arch and bulged beyond the left subclavian artery, where the other two intimal lacerations were observed. The dilated false lumen accounted for a widened cardiovascular image on
Address correspondence and reprint requests to Dr. Wang Zhong Gao, Vascular Institute, First Affiliate Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310002, China. E-mail: [email protected] • Date of acceptance: 8th October, 2002 © 2003 Elsevier. All rights reserved.
117
ASIAN JOURNAL OF SURGERY VOL 26 • NO 2 • APRIL 2003
02002
117
■ WANG AND OTHERS ■
standard chest X-ray. No signs of aortic valve regurgitation were present. After admission, she had repeated cardiac angina with ST segment elevation on electrocardiography. The severe pain could not be controlled effectively with the opium receptor activator, Tramadol. Endovascular treatment was devised according to the measurements obtained from MRI and sonography. Two endografts were prepared with a silk-covered stainless steel Zstent, which had been approved for clinical trial by the China Drug Administration. A diameter of 38 mm and length of 70 mm were chosen. Then one designated endograft was placed in the ascending and proximal descending aorta in order to close all intimal tears. The operation was performed on January 22, 2001. Via a left iliac approach, an F24 delivery system loaded with one endograft at its tip was introduced into the distal left external iliac artery. Difficulties were encountered in passing the two 90˚ curves along the distal and proximal aortic arches. When the sinotubular junction was ultimately reached, the tip of the endograft was found to be clearly located beyond the intimal tear of the ascending aorta. The process of endograft
A
C
118
deployment was very difficult, but was made from the aortic sinuses to the innominate artery. However, the patient had a severe transient ischaemic attack (TIA), including loss of consciousness, seizure and ptyalism, which lasted for about 1 minute, interrupting the endograft procedure. As rescue work was performed by the anaesthetist, the endograft was fully delivered and expanded quickly. As soon as it was finished, the patient recovered from TIA. Two minutes later, angiography showed sealing of the the intimal tears and disappearance of the false lumen. The normal diameter of the entire aorta was restored (Figure, D); thus, the second graft was no longer necessary. The patient was discharged after 10 days. She had high fever for 3 days and unusual cough for 2 weeks later after deployment of the endograft, the latter perhaps related to a stimulation of the right bronchus by the large endograft. One month after discharge until the date of this report, after more than 1 year of follow-up, she had resumed light labour of working as a clerk, without discomfort. Follow-up examination by computed tomography revealed no sign of dissection at any level of the aorta.
B
D
Figure. Angiography of the patient on admission (A–C) showing the intimal tear visible in the ascending aorta, with the false lumen, under tension, squeezing the true lumen to a tiny channel (A). The dissection proceeds along the arch, bulging beyond the left subclavian artery. As the contrast medium spreads further, more squeezing of the aorta likely to jeopardize the coronary perfusion can be seen (B). The dissection continues along the descending aorta, squeezing the true lumen into a tiny lumen (C). D) After deployment of the endograft in the ascending aorta, the intimal tear is closed, the false lumen has disappeared along the entire extent of the vessel, and the true lumen has resumed its normal diameter.
ASIAN JOURNAL OF SURGERY VOL 26 • NO 2 • APRIL 2003
02002
■ ENDOGRAFT TO REVERSE TYPE A AORTIC DISSECTION ■
Discussion This is the first reported case of a patient with acute type A dissection for which a stent graft was successfully deployed into the ascending aorta using the endoluminal technique, sealing multiple intimal tears and repairing the dissection all along the vessel. This procedure may be considered for the treatment of acute type A dissection when the intimal tear is located in the ascending aorta. Thus, the spectrum of high-risk open surgical operations can be averted. Total disappearance of the false lumen leads one to think of a possible healed dissection because the early re-assemblage of the aortic wall could preserve the elastic layer. This occurrence is certainly responsible for the 20% survival rate 20 years after surgery.3 By contrast, patency of the distal false lumen after surgery foretells late pathology and eventual death. We questioned whether total aortic replacement was the treatment of choice for type A aortic dissection.4 However, in light of the results
119
ASIAN JOURNAL OF SURGERY VOL 26 • NO 2 • APRIL 2003
02002
obtained with the present case, the concept of total replacement should be postponed until the evolving endovascular technique can be performed endoluminally.5
References 1. Ehrlich MP, Ergin MA, McCullough JN, et al. Results of immediate surgical treatment of all acute type A dissections. Circulation 2000; 102(Suppl 3):III248–52. 2. Kawahito K, Adachi H, Yamaguchi A, Ino T. Early and late surgical outcomes of acute type A aortic dissection in patients aged 75 years and older. Ann Thorac Surg 2000;70:1455–9. 3. Barron DJ, Livesey SA, Brown IW, et al. Twenty-year follow-up of acute type A dissection: the incidence and extent of distal aortic disease using magnetic resonance imaging. J Card Surg 1997;12:147–59. 4. Massimo CG, Presenti LF, Favi PP, et al. Simultaneous total aortic replacement from valve to bifurcation: experience with 21 cases. Ann Thorac Surg 1993;56:1110–6. 5. Massimo CG, Wang ZG, Cruz EAG, et al. Endoluminal replacement of the entire aorta for acute type A aortic dissection in a patient with Marfan syndrome. J Thorac Cardiovasc Surg 2000;120:818–20.
119