- Email: [email protected]
Inverted Valve After Initially Successful Transfemoral Aortic Valve Implantation
636
CASE REPORT DAMÉN ET AL INVERTED TRANSFEMORAL AORTIC VALVE
Ann Thorac Surg 2012;94:636 –9
provided freedom from mucocele recurrence at 15 months later. Definitive management of a recurrent mucocele requires eradication of residual mucosa to eliminate mucin production. We believe that image-guided ablation with absolute alcohol is a viable, minimally invasive approach for recurrent mucocele management, as decompression alone in the setting of persistently secretory esophageal tissue may not be an effective strategy. In the future, chemical ablation of residual tissue at the time of surgical intervention may be a consideration, decreasing the risk of mucocele recurrence.
Fig 2. A small pigtail catheter (white arrow) was placed into the mucocele. Aspiration was followed by contrast injection (shown) to ensure absent communication with vital structures. A similar amount of absolute alcohol was injected once the contrast was removed. Alcohol was left in place while the patient was placed in multiple positions, similar to pleurodesis. After 4 hours, the alcohol was aspirated and the catheter was removed. The black arrow shows a needle used to instill saline into the pleural space. Hydrodissection allowed the catheter to access the mucocele without traversing the lung.
FEATURE ARTICLES
the distal esophagus, traversing the diaphragm, with mass effect on the heart, although he did not have symptoms consistent with tamponade (Fig 1B). We believe that the secretions driving mucocele recurrence originated from the small amount of residual mucosa in the very distal esophagus, just proximal to the ligature of original exclusion. The collection was first treated with CT-guided pigtail catheter drainage, which was left in place for 1 week, and then removed once the output diminished to less than 30 mL daily. The patient remained well clinically for 8 months but again experienced recurrence, which was then treated with CT-guided percutaneous absolute alcohol ablation of the cavity (Fig 2). Threemonth follow-up CT showed no evidence of recurrence, and he remains asymptomatic 15 months later.
Comment This case illustrates the acuity of a compromised airway secondary to expanding esophageal mucocele [4]. This complication is observed more commonly in the setting of benign disease, and it is important to consider in the differential diagnosis for any patient with previous esophageal exclusion and vague presenting symptoms. Complaints such as dyspnea, cough, or weight loss could be a harbinger of more serious complications [5]. Recurrent esophageal mucocele is uncommon and its management has not been well described in the literature. Although a transabdominal approach and open resection of the recurrent mucocele was considered, drainage under CT guidance was ultimately pursued. The mucocele recurred 8 months later, likely the result of persistent secretion from the remaining esophageal mucosa. The patient then underwent catheter-directed ablation of the esophageal mucosa with absolute alcohol (Fig 2). This has © 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
References 1. van Till JW, van Sandick JW, Cardozo ML, Obertop H. Symptomatic mucocele of a surgically excluded esophagus. Dis Esophagus 2002;15:96 – 8. 2. Mannell A, Epstein B. Exclusion of the oesophagus: is this a dangerous manoeuvre? Br J Surg 1984;71:442–5. 3. Deaton WR Jr, Bradshaw HH. The fate of an isolated segment of the esophagus. J Thorac Surg 1952;23:570 – 4. 4. Haddad R, Teixeira Lima R, Henrique Boasquevisque C, Antonio Marsico G. Symptomatic mucocele after esophageal exclusion. Interact Cardiovasc Thorac Surg 2008;7:742– 4. 5. Kamath MV, Ellison RG, Rubin JW, Moore HV, Pai GP. Esophageal mucocele: a complication of blind loop esophagus. Ann Thorac Surg 1987;43:263–9.
Inverted Valve After Initially Successful Transfemoral Aortic Valve Implantation Tor Damén, MD, Lena Sunnermalm, MD, Örjan Friberg, MD, PhD, Leszek Zagozdzon, MD, Bo Cederstrand, MD, and Tomas Kellert, MD Departments of Cardiothoracic Surgery and Anesthesiology, Cardiology, and Clinical Physiology, Örebro University Hospital, Örebro, Sweden
A 73-year-old woman with severe aortic stenosis was accepted for transcatheter aortic valve implantation. There was minimal paravalvular leakage after the implantation, and the patient was stable. Twelve minutes after the implantation, the arterial pressure suddenly dropped. Transesophageal echocardiography showed severe left ventricular dysfunction. Cardiopulmonary resuscitation was started, and initially was successful with a systolic blood pressure of 90 mm Hg. However, despite initiation of extracorporeal circulation support, the patient deteriorated, pulmonary edema developed, and she died. Autopsy revealed an inverted aortic valve. The reasons why the patient had cardiac arrest and an inverted transfemoral aortic valve remain unclear. (Ann Thorac Surg 2012;94:636 –9) © 2012 by The Society of Thoracic Surgeons Accepted for publication Nov 28, 2011. Address correspondence to Dr Damén, Department of Cardiothoracic Surgery and Anesthesiology, Örebro University Hospital, Örebro SE-701 85, Sweden; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.11.077
Ann Thorac Surg 2012;94:636 –9
CASE REPORT DAMÉN ET AL INVERTED TRANSFEMORAL AORTIC VALVE
637
T
reatment of aortic stenosis in an elderly patient with multiple comorbidities is a controversial subject [1]. Transcatheter aortic valve implantation offers an alternative to conventional surgery for high-risk patients [2]. In our case, an elderly woman with aortic stenosis and significant comorbidities underwent a transfemoral aortic valve implantation with initial success, but she deteriorated suddenly after 12 minutes, and cardiopulmonary resuscitation (CPR) was unsuccessful. The autopsy revealed an inverted aortic valve.
Fig 1. The aortic annulus was assessed to 21 mm.
Fig 2. Radiologic evidence of the correctly implanted 23-mm Edwards Sapien aortic valve. Note the diamond shaped cells in the stent frame facing upward, to the left.
what was considered to be an adequate valve position was confirmed with fluoroscopy. External cardiac compressions were started, and after a few minutes without amelioration, preparations for venoarterial extracorporeal membrane oxygenation (ECMO) was initialized. Initially, CPR was successful, with a systolic blood pressure of 90 mm Hg. However, after 20 minutes of CPR, as the ECMO treatment started, blood pressure was no longer measurable. During ECMO, the patient had severe pulmonary edema. At that point, TEE showed an akinetic and dilated left ventricle, whereas coronary angiography showed a patent left coronary artery (Fig 4). The unsuccessful ECMO treatment was terminated after 20 minutes.
Fig 3. Minimal paravalvular leakage.
FEATURE ARTICLES
A 73-year-old woman and former smoker with diabetes mellitus, hypertension, and atrial fibrillation was accepted for transcatheter aortic valve implantation. She had a history of a previous cerebral transitory ischemic attack and four myocardial infarctions, and had undergone a coronary artery bypass surgery (2001) and two percutaneous coronary interventions (2008 and 2009). Echocardiography showed severe aortic stenosis, a left ventricular ejection fraction of 30%, and moderate right ventricular dysfunction. The logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 22.5% [3]. A transfemoral approach was chosen for the procedure, which was performed under general anesthesia. The aortic annulus was assessed to 21 mm with intraoperative transesophageal echocardiography (TEE [Fig 1]) [4]. Two balloon dilations were performed during rapid pacing, followed by the implantation of a 23-mm Edwards SAPIEN aortic valve (Edwards Lifesciences, Irvine, CA). The implantation was uneventful and considered successful (Fig 2). There was minimal paravalvular leakage, and the patient was stable with merely a low dose of norepinephrine (Fig 3). During closure of the iliac access site, 12 minutes after implantation, the patient’s systolic pressure suddenly dropped below 40 mm Hg. There were no alterations in the electrocardiogram, but TEE showed severe left ventricular dilation with systolic dysfunction. No improvement occurred after administration of epinephrine. Contrast angiography showed no aortoiliac bleeding, and
638
CASE REPORT DAMÉN ET AL INVERTED TRANSFEMORAL AORTIC VALVE
Ann Thorac Surg 2012;94:636 –9
Fig 6. Autopsy revealed an inverted aortic valve. The diamond shaped cells in the stent frame are facing downward toward the left chamber. Fig 4. Reevaluation of this radiography shows an inverted aortic valve. Note the diamond shaped cells in the stent frame facing downward.
FEATURE ARTICLES
Why the patient had cardiac arrest and an inverted transfemoral aortic valve remains unclear. Theoretically, two
options exist. Either the valve dislodged into the ventricle causing hemodynamic collapse and then, during CPR, returned inverted into the valvular plane, further compromising the circulation, or the circulation collapsed, for reasons not fully elucidated, and the valve was both dislodged and rotated during CPR. Possible reasons for a spontaneous dislodgement could be an inferior/ventricular deployment of the stent valve, or undersizing of the stent [5]. However, our retrospective evaluation was unable to confirm any of these findings. Dislocation of the prosthesis could also be an effect of a noticed difference in degree of calcification and thereby impairment of movement of the three cusps. The noncoronary cusp was severely calcified and almost fixed, in contrast to the left and right ones, which both showed signs of degeneration but not to the same extent (Fig 7). In our considered opinion, the valve was correctly implanted at the annular level, and the aortic annulus
Fig 5. Autopsy revealed an inverted aortic valve.
Fig 7. The noncoronary cusp was severely calcified and almost fixed in contrast to the left and right ones.
Autopsy revealed an inverted aortic valve (Figs 5 and 6). On reevaluation of the coronary angiography performed during ECMO, the inverted valve was evident. The aortic valve was initially correctly and successfully implanted. Careful reexaminations of radiologic and echocardiographic sequences proved that beyond doubt. These observations are strongly supported by the observation that, initially after the implantation, the patient showed stable hemodynamics.
Comment
CASE REPORT STANLEY ET AL ANOMALOUS SUBCLAVIAN ARTERY DISSECTION REPAIR
was, as noted, 21 mm on TEE. Repeat postoperative evaluations of the preoperative and intraoperative annular measurements have not yielded any different assessments of its size.
associated with an aortic outpouching at the vessel origin [1], known as a Kommerell diverticulum (KD). Symptoms and complications occur with aneurysmal degeneration of this diverticulum or the ARSA as a result of focal compression of adjacent structures, distal embolization, and rupture. Despite the rarity of ARSA aneurysms, a growing number of reports in the literature have offered sound surgical indications and multiple surgical treatment strategies [1– 4]. We report a two-stage hybrid endovascular repair for acute dissection of a retroesophageal ARSA arising from a left aortic arch in a patient with Marfan syndrome.
References 1. Makkar R, Fontana G, Jilaihawi H, et al. Transcatheter aortic valve replacement for inoperable severe aortic stenosis. N Engl J Med 2012;366:1696 –704. 2. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2011;363:1597– 607. 3. EuroSCORE, the European System for Cardiac Operative Risk Evaluation. Available at: http://www.euroscore.org/ logisticEuroSCORE.htm. Accessed June 27, 2012. 4. Messika-Zeitour D, Serfaty J-M, Brochet E, et al. Multimodal assessment of the aortic annulus diameter: implications for transcatheter aortic valve implantation. J Am Coll Cardiol 2010;55:186 –94. 5. Piazza N, de Jaegere P, Schultz C, et al. Anatomy of the aortic valvar complex and its implications for transcatheter implantation of the aortic valve. Circ Cardiovasc Intervent 2008;1:74 – 81.
Hybrid Endovascular Treatment of an Anomalous Right Subclavian Artery Dissection in a Patient With Marfan Syndrome Gregory A. Stanley, MD, Frank R. Arko III, MD, Mazin I. Foteh, MD, Michael E. Jessen, MD, and J. Michael DiMaio, MD Division of Vascular and Endovascular Surgery, and Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
We report the case of a 26-year-old female patient with Marfan syndrome and an aberrant right subclavian artery (ARSA) with associated Kommerell diverticulum. The patient presented with spontaneous acute dissection of the ARSA that showed fusiform dilation to 4 cm in diameter. Definitive treatment was performed using a two-stage hybrid endovascular technique, including extrathoracic bilateral upper extremity bypass and thoracic endovascular aortic repair with debranching of the right and left subclavian arteries. This was followed by coil and plug embolization to exclude the dissection and prevent subsequent endoleak. (Ann Thorac Surg 2012;94:639 – 41) © 2012 by The Society of Thoracic Surgeons
A
n aberrant right subclavian artery (ARSA) is a common congenital aortic arch abnormality, occurring in 0.4% to 2% of the general population [1]. Up to 60% are
Accepted for publication Dec 19, 2011. Address correspondence to Dr DiMaio, Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, 5909 Harry Hines Blvd, 9th Fl, Ste 134, Dallas, TX 75390-8879; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
A 26-year-old female patient with Marfan syndrome was referred to our institution after presenting to a community hospital with a 2-day history of worsening thoracic back pain radiating to the precordium. The patient previously underwent four prior sternotomies to replace her aortic valve and ascending aorta secondary to aneurysmal dilatation with resultant valvular insufficiency. The most recent surgery was complicated by sternal dehiscence and a prolonged hospital course. A computed tomographic angiography (CTA) of the chest was obtained and revealed a left aortic arch with ARSA and KD (Fig 1). The ARSA had fusiform dilatation from its origin at the level of the left subclavian artery to the right vertebral artery, coursing in a retroesophageal location. In addition, an acute focal dissection was identified in the middle segment of the ARSA, measuring 40 mm in diameter. The patient was in stable condition with persistent left upper back and chest pain. Blood pressure measurements of the right and left upper extremity were within normal limits and not significantly different. The patient was taken to the operating room for a planned two-stage hybrid endovascular approach to definitively exclude the KD and ARSA dissection. A thoracic aortogram was obtained to confirm the CTA findings (Fig 2A). Extrathoracic revascularization of the upper extremities was accomplished with a left carotid-tobiaxillary bypass using 8 mm of polytetrafluoroethylene (PTFE) through a left neck and bilateral infraclavicular incisions; this was followed by deployment of a Talent thoracic stent graft with Captiva Delivery System (Medtronic, Santa Rosa, CA), debranching the right and left subclavian arteries. Completion aortogram showed exclusion of the ARSA with minimal antegrade flow in the left subclavian artery and retrograde filling from the extrathoracic bypass grafts (Fig 2B). The following day, the second stage proceeded with placement of a 10-mm Amplatzer vascular plug (AGA Medical, Plymouth, Minnesota) in the proximal left subclavian artery to prevent a type 2 endoleak at this location. The ARSA and KD were then excluded by coil embolization using Azur hydrocoils (Terumo Interventional Systems, Somerset, NJ) ranging in size from 8 to 20 mm in diameter. A transesophageal echocardiogram (TEE) was performed to assess flow in the ARSA both before and after coil deployment. Finally, a 16-mm Amplatzer plug was placed in the ARSA just proximal to the 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.12.082
FEATURE ARTICLES
639
Ann Thorac Surg 2012;94:639 – 41
CASE REPORT DAMÉN ET AL INVERTED TRANSFEMORAL AORTIC VALVE
Ann Thorac Surg 2012;94:636 –9
provided freedom from mucocele recurrence at 15 months later. Definitive management of a recurrent mucocele requires eradication of residual mucosa to eliminate mucin production. We believe that image-guided ablation with absolute alcohol is a viable, minimally invasive approach for recurrent mucocele management, as decompression alone in the setting of persistently secretory esophageal tissue may not be an effective strategy. In the future, chemical ablation of residual tissue at the time of surgical intervention may be a consideration, decreasing the risk of mucocele recurrence.
Fig 2. A small pigtail catheter (white arrow) was placed into the mucocele. Aspiration was followed by contrast injection (shown) to ensure absent communication with vital structures. A similar amount of absolute alcohol was injected once the contrast was removed. Alcohol was left in place while the patient was placed in multiple positions, similar to pleurodesis. After 4 hours, the alcohol was aspirated and the catheter was removed. The black arrow shows a needle used to instill saline into the pleural space. Hydrodissection allowed the catheter to access the mucocele without traversing the lung.
FEATURE ARTICLES
the distal esophagus, traversing the diaphragm, with mass effect on the heart, although he did not have symptoms consistent with tamponade (Fig 1B). We believe that the secretions driving mucocele recurrence originated from the small amount of residual mucosa in the very distal esophagus, just proximal to the ligature of original exclusion. The collection was first treated with CT-guided pigtail catheter drainage, which was left in place for 1 week, and then removed once the output diminished to less than 30 mL daily. The patient remained well clinically for 8 months but again experienced recurrence, which was then treated with CT-guided percutaneous absolute alcohol ablation of the cavity (Fig 2). Threemonth follow-up CT showed no evidence of recurrence, and he remains asymptomatic 15 months later.
Comment This case illustrates the acuity of a compromised airway secondary to expanding esophageal mucocele [4]. This complication is observed more commonly in the setting of benign disease, and it is important to consider in the differential diagnosis for any patient with previous esophageal exclusion and vague presenting symptoms. Complaints such as dyspnea, cough, or weight loss could be a harbinger of more serious complications [5]. Recurrent esophageal mucocele is uncommon and its management has not been well described in the literature. Although a transabdominal approach and open resection of the recurrent mucocele was considered, drainage under CT guidance was ultimately pursued. The mucocele recurred 8 months later, likely the result of persistent secretion from the remaining esophageal mucosa. The patient then underwent catheter-directed ablation of the esophageal mucosa with absolute alcohol (Fig 2). This has © 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
References 1. van Till JW, van Sandick JW, Cardozo ML, Obertop H. Symptomatic mucocele of a surgically excluded esophagus. Dis Esophagus 2002;15:96 – 8. 2. Mannell A, Epstein B. Exclusion of the oesophagus: is this a dangerous manoeuvre? Br J Surg 1984;71:442–5. 3. Deaton WR Jr, Bradshaw HH. The fate of an isolated segment of the esophagus. J Thorac Surg 1952;23:570 – 4. 4. Haddad R, Teixeira Lima R, Henrique Boasquevisque C, Antonio Marsico G. Symptomatic mucocele after esophageal exclusion. Interact Cardiovasc Thorac Surg 2008;7:742– 4. 5. Kamath MV, Ellison RG, Rubin JW, Moore HV, Pai GP. Esophageal mucocele: a complication of blind loop esophagus. Ann Thorac Surg 1987;43:263–9.
Inverted Valve After Initially Successful Transfemoral Aortic Valve Implantation Tor Damén, MD, Lena Sunnermalm, MD, Örjan Friberg, MD, PhD, Leszek Zagozdzon, MD, Bo Cederstrand, MD, and Tomas Kellert, MD Departments of Cardiothoracic Surgery and Anesthesiology, Cardiology, and Clinical Physiology, Örebro University Hospital, Örebro, Sweden
A 73-year-old woman with severe aortic stenosis was accepted for transcatheter aortic valve implantation. There was minimal paravalvular leakage after the implantation, and the patient was stable. Twelve minutes after the implantation, the arterial pressure suddenly dropped. Transesophageal echocardiography showed severe left ventricular dysfunction. Cardiopulmonary resuscitation was started, and initially was successful with a systolic blood pressure of 90 mm Hg. However, despite initiation of extracorporeal circulation support, the patient deteriorated, pulmonary edema developed, and she died. Autopsy revealed an inverted aortic valve. The reasons why the patient had cardiac arrest and an inverted transfemoral aortic valve remain unclear. (Ann Thorac Surg 2012;94:636 –9) © 2012 by The Society of Thoracic Surgeons Accepted for publication Nov 28, 2011. Address correspondence to Dr Damén, Department of Cardiothoracic Surgery and Anesthesiology, Örebro University Hospital, Örebro SE-701 85, Sweden; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.11.077
Ann Thorac Surg 2012;94:636 –9
CASE REPORT DAMÉN ET AL INVERTED TRANSFEMORAL AORTIC VALVE
637
T
reatment of aortic stenosis in an elderly patient with multiple comorbidities is a controversial subject [1]. Transcatheter aortic valve implantation offers an alternative to conventional surgery for high-risk patients [2]. In our case, an elderly woman with aortic stenosis and significant comorbidities underwent a transfemoral aortic valve implantation with initial success, but she deteriorated suddenly after 12 minutes, and cardiopulmonary resuscitation (CPR) was unsuccessful. The autopsy revealed an inverted aortic valve.
Fig 1. The aortic annulus was assessed to 21 mm.
Fig 2. Radiologic evidence of the correctly implanted 23-mm Edwards Sapien aortic valve. Note the diamond shaped cells in the stent frame facing upward, to the left.
what was considered to be an adequate valve position was confirmed with fluoroscopy. External cardiac compressions were started, and after a few minutes without amelioration, preparations for venoarterial extracorporeal membrane oxygenation (ECMO) was initialized. Initially, CPR was successful, with a systolic blood pressure of 90 mm Hg. However, after 20 minutes of CPR, as the ECMO treatment started, blood pressure was no longer measurable. During ECMO, the patient had severe pulmonary edema. At that point, TEE showed an akinetic and dilated left ventricle, whereas coronary angiography showed a patent left coronary artery (Fig 4). The unsuccessful ECMO treatment was terminated after 20 minutes.
Fig 3. Minimal paravalvular leakage.
FEATURE ARTICLES
A 73-year-old woman and former smoker with diabetes mellitus, hypertension, and atrial fibrillation was accepted for transcatheter aortic valve implantation. She had a history of a previous cerebral transitory ischemic attack and four myocardial infarctions, and had undergone a coronary artery bypass surgery (2001) and two percutaneous coronary interventions (2008 and 2009). Echocardiography showed severe aortic stenosis, a left ventricular ejection fraction of 30%, and moderate right ventricular dysfunction. The logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 22.5% [3]. A transfemoral approach was chosen for the procedure, which was performed under general anesthesia. The aortic annulus was assessed to 21 mm with intraoperative transesophageal echocardiography (TEE [Fig 1]) [4]. Two balloon dilations were performed during rapid pacing, followed by the implantation of a 23-mm Edwards SAPIEN aortic valve (Edwards Lifesciences, Irvine, CA). The implantation was uneventful and considered successful (Fig 2). There was minimal paravalvular leakage, and the patient was stable with merely a low dose of norepinephrine (Fig 3). During closure of the iliac access site, 12 minutes after implantation, the patient’s systolic pressure suddenly dropped below 40 mm Hg. There were no alterations in the electrocardiogram, but TEE showed severe left ventricular dilation with systolic dysfunction. No improvement occurred after administration of epinephrine. Contrast angiography showed no aortoiliac bleeding, and
638
CASE REPORT DAMÉN ET AL INVERTED TRANSFEMORAL AORTIC VALVE
Ann Thorac Surg 2012;94:636 –9
Fig 6. Autopsy revealed an inverted aortic valve. The diamond shaped cells in the stent frame are facing downward toward the left chamber. Fig 4. Reevaluation of this radiography shows an inverted aortic valve. Note the diamond shaped cells in the stent frame facing downward.
FEATURE ARTICLES
Why the patient had cardiac arrest and an inverted transfemoral aortic valve remains unclear. Theoretically, two
options exist. Either the valve dislodged into the ventricle causing hemodynamic collapse and then, during CPR, returned inverted into the valvular plane, further compromising the circulation, or the circulation collapsed, for reasons not fully elucidated, and the valve was both dislodged and rotated during CPR. Possible reasons for a spontaneous dislodgement could be an inferior/ventricular deployment of the stent valve, or undersizing of the stent [5]. However, our retrospective evaluation was unable to confirm any of these findings. Dislocation of the prosthesis could also be an effect of a noticed difference in degree of calcification and thereby impairment of movement of the three cusps. The noncoronary cusp was severely calcified and almost fixed, in contrast to the left and right ones, which both showed signs of degeneration but not to the same extent (Fig 7). In our considered opinion, the valve was correctly implanted at the annular level, and the aortic annulus
Fig 5. Autopsy revealed an inverted aortic valve.
Fig 7. The noncoronary cusp was severely calcified and almost fixed in contrast to the left and right ones.
Autopsy revealed an inverted aortic valve (Figs 5 and 6). On reevaluation of the coronary angiography performed during ECMO, the inverted valve was evident. The aortic valve was initially correctly and successfully implanted. Careful reexaminations of radiologic and echocardiographic sequences proved that beyond doubt. These observations are strongly supported by the observation that, initially after the implantation, the patient showed stable hemodynamics.
Comment
CASE REPORT STANLEY ET AL ANOMALOUS SUBCLAVIAN ARTERY DISSECTION REPAIR
was, as noted, 21 mm on TEE. Repeat postoperative evaluations of the preoperative and intraoperative annular measurements have not yielded any different assessments of its size.
associated with an aortic outpouching at the vessel origin [1], known as a Kommerell diverticulum (KD). Symptoms and complications occur with aneurysmal degeneration of this diverticulum or the ARSA as a result of focal compression of adjacent structures, distal embolization, and rupture. Despite the rarity of ARSA aneurysms, a growing number of reports in the literature have offered sound surgical indications and multiple surgical treatment strategies [1– 4]. We report a two-stage hybrid endovascular repair for acute dissection of a retroesophageal ARSA arising from a left aortic arch in a patient with Marfan syndrome.
References 1. Makkar R, Fontana G, Jilaihawi H, et al. Transcatheter aortic valve replacement for inoperable severe aortic stenosis. N Engl J Med 2012;366:1696 –704. 2. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2011;363:1597– 607. 3. EuroSCORE, the European System for Cardiac Operative Risk Evaluation. Available at: http://www.euroscore.org/ logisticEuroSCORE.htm. Accessed June 27, 2012. 4. Messika-Zeitour D, Serfaty J-M, Brochet E, et al. Multimodal assessment of the aortic annulus diameter: implications for transcatheter aortic valve implantation. J Am Coll Cardiol 2010;55:186 –94. 5. Piazza N, de Jaegere P, Schultz C, et al. Anatomy of the aortic valvar complex and its implications for transcatheter implantation of the aortic valve. Circ Cardiovasc Intervent 2008;1:74 – 81.
Hybrid Endovascular Treatment of an Anomalous Right Subclavian Artery Dissection in a Patient With Marfan Syndrome Gregory A. Stanley, MD, Frank R. Arko III, MD, Mazin I. Foteh, MD, Michael E. Jessen, MD, and J. Michael DiMaio, MD Division of Vascular and Endovascular Surgery, and Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
We report the case of a 26-year-old female patient with Marfan syndrome and an aberrant right subclavian artery (ARSA) with associated Kommerell diverticulum. The patient presented with spontaneous acute dissection of the ARSA that showed fusiform dilation to 4 cm in diameter. Definitive treatment was performed using a two-stage hybrid endovascular technique, including extrathoracic bilateral upper extremity bypass and thoracic endovascular aortic repair with debranching of the right and left subclavian arteries. This was followed by coil and plug embolization to exclude the dissection and prevent subsequent endoleak. (Ann Thorac Surg 2012;94:639 – 41) © 2012 by The Society of Thoracic Surgeons
A
n aberrant right subclavian artery (ARSA) is a common congenital aortic arch abnormality, occurring in 0.4% to 2% of the general population [1]. Up to 60% are
Accepted for publication Dec 19, 2011. Address correspondence to Dr DiMaio, Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, 5909 Harry Hines Blvd, 9th Fl, Ste 134, Dallas, TX 75390-8879; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
A 26-year-old female patient with Marfan syndrome was referred to our institution after presenting to a community hospital with a 2-day history of worsening thoracic back pain radiating to the precordium. The patient previously underwent four prior sternotomies to replace her aortic valve and ascending aorta secondary to aneurysmal dilatation with resultant valvular insufficiency. The most recent surgery was complicated by sternal dehiscence and a prolonged hospital course. A computed tomographic angiography (CTA) of the chest was obtained and revealed a left aortic arch with ARSA and KD (Fig 1). The ARSA had fusiform dilatation from its origin at the level of the left subclavian artery to the right vertebral artery, coursing in a retroesophageal location. In addition, an acute focal dissection was identified in the middle segment of the ARSA, measuring 40 mm in diameter. The patient was in stable condition with persistent left upper back and chest pain. Blood pressure measurements of the right and left upper extremity were within normal limits and not significantly different. The patient was taken to the operating room for a planned two-stage hybrid endovascular approach to definitively exclude the KD and ARSA dissection. A thoracic aortogram was obtained to confirm the CTA findings (Fig 2A). Extrathoracic revascularization of the upper extremities was accomplished with a left carotid-tobiaxillary bypass using 8 mm of polytetrafluoroethylene (PTFE) through a left neck and bilateral infraclavicular incisions; this was followed by deployment of a Talent thoracic stent graft with Captiva Delivery System (Medtronic, Santa Rosa, CA), debranching the right and left subclavian arteries. Completion aortogram showed exclusion of the ARSA with minimal antegrade flow in the left subclavian artery and retrograde filling from the extrathoracic bypass grafts (Fig 2B). The following day, the second stage proceeded with placement of a 10-mm Amplatzer vascular plug (AGA Medical, Plymouth, Minnesota) in the proximal left subclavian artery to prevent a type 2 endoleak at this location. The ARSA and KD were then excluded by coil embolization using Azur hydrocoils (Terumo Interventional Systems, Somerset, NJ) ranging in size from 8 to 20 mm in diameter. A transesophageal echocardiogram (TEE) was performed to assess flow in the ARSA both before and after coil deployment. Finally, a 16-mm Amplatzer plug was placed in the ARSA just proximal to the 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.12.082
FEATURE ARTICLES
639
Ann Thorac Surg 2012;94:639 – 41