Successful surgery in a patient with a rupture of descending aorta complicated by acute type A aortic dissection through left-sided thoracot
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《血管的通路杂志》
Kobe University Graduate School of Medicine, Department of Cardiovascular, Thoracic, and Pediatric Surgery, Kobe, Japan
Abstract
A 42-year-old man complaining of severe chest pain was referred to our hospital. Computed tomography demonstrated acute type A aortic dissection complicated with rupture in the descending aorta and right leg malperfusion. Initial entry was detected in the proximal descending aorta. He underwent aortic arch, and descending thoracic aorta replacement using selective cerebral perfusion through a left thoracotomy. The leg malperfusion was treated successfully by endovascular treatment on 18th day after the operation. The chest computed tomography three month after surgery demonstrated the disappearance of the false lumen proximal to the anastomotic site and satisfactory outcome.
Key Words: Acute type A aortic dissection; Descending aortic rupture; Left thoracotomy
1. Introduction
Descending aortic rupture complicated with acute type A aortic dissection is rare [1]. This condition is often fatal and treatment is always associated with some difficulties. Some surgical options are considered; two stage approach: endovascular repair of the descending aorta followed by open-surgical repair of the proximal segment; single stage approach: open-surgery through the midline with distal stent introduction. However, the result of stent-graft placement for aortic rupture complicated with aortic dissection had been unknown [2,3], and there is an increased risk of proximal aortic rupture during the interval from the first procedure to the second procedure. In this report, we describe a patient with rupture of descending thoracic aorta complicated with acute type A dissection who underwent single stage arch and descending aorta replacement using selective cerebral perfusion through a left thoracotomy.
2. Case report
A 42-year-old man had been suffering from vague back pain and abdominal pain for a week. He showed weakened pulse of the right femoral artery. On the day of admission, a sudden onset of severe anterior chest pain occurred, and his chest computed tomography demonstrated acute type A aortic dissection complicated with a descending aortic rupture just above the diaphragm. Computed tomography also showed that the false lumen of the proximal aorta was partially thrombosed and the left renal artery was originated from the false lumen (Fig. 1). He underwent emergent surgery of replacement of the arch and descending thoracic aorta.
In the right recumbent position, entire thoracic aorta was exposed through a left rib-cross thoracotomy. A skin incision was made from the midpoint between the spinal process and the scapula, around the lower end point of the scapula, down to the left subchorondal lesion. The fourth and seventh intercostal spaces were opened, and then, the fifth, sixth, and seventh ribs were transected at the midaxillar line. The eighth costal cartilage was transected along the incision through the seventh intercostal space. The sternum was not transected and the left internal thoracic artery was preserved. Cardiopulmonary bypass was established using the left femoral artery for arterial inflow and the pulmonary artery for venous outflow, and the patient was cooled down to a tympanic temperature of 24 °C. After the aortic clamp was placed just above the diaphragm and perfusion of the lower body was maintained, the aorta was opened from the descending aorta to the ascending aorta. The adventitial rupture site was identified at Th-8 level, and the intimal tear was located just distal to the left subclavian artery. Cardioplegic solution was given to the ascending aorta with a balloon tipped catherter, and selective cerebral perfusion from inside the arch vessels was established. Proximal false lumen of the ascending aorta was almost thrombosed. Distal ascending aorta was transected and reapproximated with felt strip outside and equine pericardial patch inside putting glue into the false lumen. A 24-mm knitted Dacron graft was anastomosed to the ascending aorta, and arch vessels were reconstructed as an island cuff. Perfusion to the heart and brain was resumed through the side branch of the graft. Distally, the aorta was transected at Th-9 level, and the graft was anastomosed to both the true and false lumen in order to prevental malperfusion of the left renal artery. The patient recovered uneventfully. Postoperative angiogram and computed tomography demonstrated a stenosis of the true lumen at the aortic bifurcation compressed by the false lumen. The endovascular stent insertion in the true lumen was done successfully. The patient was discharged and went back to normal life. Chest computed tomography at three months after surgery demonstrated a disappearance of the false lumen of the proximal ascending aorta (Fig. 2).
3. Discussion
Rupture of descending thoracic aorta complicated with acute type A aortic dissection is rare and also fatal [1]. The treatment of this entity allows some approaches; surgical treatment combined with stent graft insertion, or single-stage surgical approach. The outcome of the stent graft insertion for descending aortic rupture complicated with acute aortic dissection is uncertain [2,3], and in this case, the patient had more possibility of proximal aortic rupture during the interval when the two-stage approach was applied. Under such an emergent circumstance, a single-stage surgical approach seemed to be optimal. We decided to replace the entire aorta including the entry, rupture site, and proximal patent false lumen through a left thoracotomy. Rib-cross thoracotomy provides an excellent exposure of the entire thoracic aorta. We usually use this approach for extensive aortic disease such as thoracoabdominal aneurysm [4]. Replacements of the entire thoracic aorta through median sternotomy with a small thoracotomy have been reported, however, it demonstrated high mortality and morbidity because of technical difficulties especially in the manipulation of the descending thoracic aorta [5,6]. In this case, the approach of sternotomy with a small thoracotomy was unreliable in regard to the manipulation of the ruptured descending thoracic aorta, so we decided the approach as aleft thoracotomy. The proximal ascending aorta in which no intimal tear was identified was not replaced. The entire ascending aorta was not necessary to replace, because the aorta was 38 mm in diameter and the intimal tear in the thoracic aorta was completely resected, and the proximal reapproximation technique with glue was reliable which would make the proximal false lumen to be thrombosed and reduced after surgery.
We believe this approach may be a good alternative as a single stage procedure in such a patient who needs extensive thoracic aortic replacement.
References
Lindsay J Jr., Hurst JW. Clinical features and prognosis in dissection aneurysms of the aorta: a re-appraisal. Circulation 1967;35:880–888.
Dake MD, Kato N, Mitchell RS, Semba CP, Razavi MK, Shimono T. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340:1546–1552.
Kawamura S, Nishimaki H, Lin ZB, Machii M, Isobe Y, Hayakawa K, Soma K. Emergent endovascular stent-graft placement to treat ruptured Stanford type B acute aortic dissection. J Vasc Surg 2004;39:668–671.
Tsukube T, Yoshimura M, Matsuda H, Okada K, Okita Y. Rib-cross thoracotomy for replacement of the thoracoabdominal or total descending aorta. J Vasc Surg 2003;37:219–221.
Buffolo E, Fonseca HP, Andrade JCS, Branco JNR, Carvalho ACC. Surgical treatment of acute type B aortic dissection using the elephant trunk principle. J Cardiovasc Surg 1992;33:59–60.
Beaver TM, Martin TD. Single-stage transmediastinal replacement of the ascending, arch, and descending thoracic aorta. Ann Thorac Surg 2001;72:1232–1238.(Hiroshi Tanaka, Teruo Yam)
Abstract
A 42-year-old man complaining of severe chest pain was referred to our hospital. Computed tomography demonstrated acute type A aortic dissection complicated with rupture in the descending aorta and right leg malperfusion. Initial entry was detected in the proximal descending aorta. He underwent aortic arch, and descending thoracic aorta replacement using selective cerebral perfusion through a left thoracotomy. The leg malperfusion was treated successfully by endovascular treatment on 18th day after the operation. The chest computed tomography three month after surgery demonstrated the disappearance of the false lumen proximal to the anastomotic site and satisfactory outcome.
Key Words: Acute type A aortic dissection; Descending aortic rupture; Left thoracotomy
1. Introduction
Descending aortic rupture complicated with acute type A aortic dissection is rare [1]. This condition is often fatal and treatment is always associated with some difficulties. Some surgical options are considered; two stage approach: endovascular repair of the descending aorta followed by open-surgical repair of the proximal segment; single stage approach: open-surgery through the midline with distal stent introduction. However, the result of stent-graft placement for aortic rupture complicated with aortic dissection had been unknown [2,3], and there is an increased risk of proximal aortic rupture during the interval from the first procedure to the second procedure. In this report, we describe a patient with rupture of descending thoracic aorta complicated with acute type A dissection who underwent single stage arch and descending aorta replacement using selective cerebral perfusion through a left thoracotomy.
2. Case report
A 42-year-old man had been suffering from vague back pain and abdominal pain for a week. He showed weakened pulse of the right femoral artery. On the day of admission, a sudden onset of severe anterior chest pain occurred, and his chest computed tomography demonstrated acute type A aortic dissection complicated with a descending aortic rupture just above the diaphragm. Computed tomography also showed that the false lumen of the proximal aorta was partially thrombosed and the left renal artery was originated from the false lumen (Fig. 1). He underwent emergent surgery of replacement of the arch and descending thoracic aorta.
In the right recumbent position, entire thoracic aorta was exposed through a left rib-cross thoracotomy. A skin incision was made from the midpoint between the spinal process and the scapula, around the lower end point of the scapula, down to the left subchorondal lesion. The fourth and seventh intercostal spaces were opened, and then, the fifth, sixth, and seventh ribs were transected at the midaxillar line. The eighth costal cartilage was transected along the incision through the seventh intercostal space. The sternum was not transected and the left internal thoracic artery was preserved. Cardiopulmonary bypass was established using the left femoral artery for arterial inflow and the pulmonary artery for venous outflow, and the patient was cooled down to a tympanic temperature of 24 °C. After the aortic clamp was placed just above the diaphragm and perfusion of the lower body was maintained, the aorta was opened from the descending aorta to the ascending aorta. The adventitial rupture site was identified at Th-8 level, and the intimal tear was located just distal to the left subclavian artery. Cardioplegic solution was given to the ascending aorta with a balloon tipped catherter, and selective cerebral perfusion from inside the arch vessels was established. Proximal false lumen of the ascending aorta was almost thrombosed. Distal ascending aorta was transected and reapproximated with felt strip outside and equine pericardial patch inside putting glue into the false lumen. A 24-mm knitted Dacron graft was anastomosed to the ascending aorta, and arch vessels were reconstructed as an island cuff. Perfusion to the heart and brain was resumed through the side branch of the graft. Distally, the aorta was transected at Th-9 level, and the graft was anastomosed to both the true and false lumen in order to prevental malperfusion of the left renal artery. The patient recovered uneventfully. Postoperative angiogram and computed tomography demonstrated a stenosis of the true lumen at the aortic bifurcation compressed by the false lumen. The endovascular stent insertion in the true lumen was done successfully. The patient was discharged and went back to normal life. Chest computed tomography at three months after surgery demonstrated a disappearance of the false lumen of the proximal ascending aorta (Fig. 2).
3. Discussion
Rupture of descending thoracic aorta complicated with acute type A aortic dissection is rare and also fatal [1]. The treatment of this entity allows some approaches; surgical treatment combined with stent graft insertion, or single-stage surgical approach. The outcome of the stent graft insertion for descending aortic rupture complicated with acute aortic dissection is uncertain [2,3], and in this case, the patient had more possibility of proximal aortic rupture during the interval when the two-stage approach was applied. Under such an emergent circumstance, a single-stage surgical approach seemed to be optimal. We decided to replace the entire aorta including the entry, rupture site, and proximal patent false lumen through a left thoracotomy. Rib-cross thoracotomy provides an excellent exposure of the entire thoracic aorta. We usually use this approach for extensive aortic disease such as thoracoabdominal aneurysm [4]. Replacements of the entire thoracic aorta through median sternotomy with a small thoracotomy have been reported, however, it demonstrated high mortality and morbidity because of technical difficulties especially in the manipulation of the descending thoracic aorta [5,6]. In this case, the approach of sternotomy with a small thoracotomy was unreliable in regard to the manipulation of the ruptured descending thoracic aorta, so we decided the approach as aleft thoracotomy. The proximal ascending aorta in which no intimal tear was identified was not replaced. The entire ascending aorta was not necessary to replace, because the aorta was 38 mm in diameter and the intimal tear in the thoracic aorta was completely resected, and the proximal reapproximation technique with glue was reliable which would make the proximal false lumen to be thrombosed and reduced after surgery.
We believe this approach may be a good alternative as a single stage procedure in such a patient who needs extensive thoracic aortic replacement.
References
Lindsay J Jr., Hurst JW. Clinical features and prognosis in dissection aneurysms of the aorta: a re-appraisal. Circulation 1967;35:880–888.
Dake MD, Kato N, Mitchell RS, Semba CP, Razavi MK, Shimono T. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340:1546–1552.
Kawamura S, Nishimaki H, Lin ZB, Machii M, Isobe Y, Hayakawa K, Soma K. Emergent endovascular stent-graft placement to treat ruptured Stanford type B acute aortic dissection. J Vasc Surg 2004;39:668–671.
Tsukube T, Yoshimura M, Matsuda H, Okada K, Okita Y. Rib-cross thoracotomy for replacement of the thoracoabdominal or total descending aorta. J Vasc Surg 2003;37:219–221.
Buffolo E, Fonseca HP, Andrade JCS, Branco JNR, Carvalho ACC. Surgical treatment of acute type B aortic dissection using the elephant trunk principle. J Cardiovasc Surg 1992;33:59–60.
Beaver TM, Martin TD. Single-stage transmediastinal replacement of the ascending, arch, and descending thoracic aorta. Ann Thorac Surg 2001;72:1232–1238.(Hiroshi Tanaka, Teruo Yam)