Abstract An 81-year-old woman was referred to our centre for emergency surgery with a suspected diagnosis of acute aortic dissection. Laboratory tests showed marked elevation of serum creatinine and blood urea nitrogen. Enhanced computed tomography (CT) demonstrated Type A aortic dissection with a thrombosed false lumen in the ascending aorta. The primary entry tear was located 2 cm distal to the left subclavian artery. Malperfusion of bilateral renal arteries was also evident due to compression by the false lumen. Considering her poor preoperative condition, thoracic endovascular repair of the entry was performed. The primary entry tear was covered using a covered Zenith TX-D stent graft, and a supplemental non-covered Zenith TX-D stent was deployed from the distal edge of the stent graft to the infrarenal aorta. After 5 days of dialysis and additional renal angioplasty for the stenotic left renal artery, her renal function recovered to normal. Her postoperative course was uneventful. Enhanced CT 1 month after surgery showed obliteration of the false lumen of the ascending aorta and patent renal arteries bilaterally. Aortic dissection , Malperfusion , Endovascular therapy INTRODUCTION Type A acute aortic dissection (AAAD) with an entry tear in the descending aorta is a special subset of aortic dissection. Although open surgery is the standard treatment for this pathology, it is highly invasive and produces suboptimal results, especially in cases complicated with vital organ malperfusion. Alternative endovascular techniques have been reported in selected patients . Herein, we report successful thoracic endovascular repair (TEVAR) of AAAD with critical renal failure due to malperfusion of renal arteries bilaterally. CASE An 81-year-old woman with sudden onset of back pain, nausea and anuria was diagnosed at a neighbouring hospital with aortic dissection based on elevated serum creatinine and blood urea nitrogen (10.5 mg/dl and 93.0 mg/dl, respectively) and plain computed tomography (CT). She was transferred to our hospital where enhanced CT revealed AAAD (Fig. 1). The size of the ascending aorta was 39 × 42 mm with a thrombosed false lumen (10 mm in thickness), and the initial aortic entry was located 2 cm distal to the origin of the left subclavian artery. The circumference of aorta just behind the left subclavian artery was 88.2 mm. The false lumen compressed the true lumen and renal artery orifices bilaterally (Fig. 1B), suggesting static malperfusion of the kidney. Figure 1: View largeDownload slide Preoperative enhanced computed tomography. White arrow indicated the thrombosed false lumen at the ascending aorta. The ascending aorta (A), the level of renal arteries (B) and a 3-dimensional image (C). Figure 1: View largeDownload slide Preoperative enhanced computed tomography. White arrow indicated the thrombosed false lumen at the ascending aorta. The ascending aorta (A), the level of renal arteries (B) and a 3-dimensional image (C). Considering her serious renal dysfunction and old age, we planned TEVAR for the entry closure and relief from renal artery malperfusion. Under general anaesthesia, the proximal entry tear was covered by a Zenith-Dissection-tapered stent graft (diameter 32–28 mm; length 160 mm; Cook Medical, Bloomington, IN, USA), of which oversizing was approximately 110% of the circumference of the true lumen. Two non-covered aortic stents (Zenith-Dissection; 36 × 124 mm and 36 × 164 mm, Cook Medical) were deployed from the distal edge of the Zenith-Dissection endograft to the infrarenal aorta. Final angiography confirmed entry closure and flow in the renal arteries bilaterally. As enhanced CT revealed residual left renal artery stenosis, angioplasty using the placement of a 6- × 18-mm Palmaz Genesis stent (Cordis Endovascular, Miami, FL, USA) was performed to promote the recovery of renal function on postoperative day 3. Her renal function recovered to normal (serum creatinine level 0.8 mg/dl) 10 days after endovascular surgery. Enhanced CT at 3 weeks postoperatively showed regression of the false lumen of the ascending aorta and patent renal arteries bilaterally (Fig. 2). She was discharged home in a good condition 1 month after TEVAR and remained healthy without aortic events during the 1-year follow-up. Figure 2: View largeDownload slide Postoperative enhanced computed tomography. The ascending aorta (A), the level of renal arteries (B) and a 3-dimensional image (C). Figure 2: View largeDownload slide Postoperative enhanced computed tomography. The ascending aorta (A), the level of renal arteries (B) and a 3-dimensional image (C). DISCUSSION We experienced AAAD with an entry tear in the descending aorta complicated by critical renal malperfusion. We chose the least invasive endovascular approach due to a very high-risk situation. Shu et al. reported 17 patients with poor clinical health status who were treated using TEVAR. All patients survived over a mean follow-up period of 25 months, with good aortic remodelling. They concluded that TEVAR is safe and effective for this aortic pathology in highly selected patients . In addition to entry closure using the stent graft, we used a bare metal aortic stent for definitive expansion of the true lumen and relief of renal malperfusion. Since Nienaber et al. first reported the PETTICOAT technique in a series of supplemental bare metal stents in TEVAR treatment, its effectiveness is now accepted, especially for aortic dissection complicated with organ malperfusion [2, 3]. In this particular case, we incidentally identified residual stenosis of the left renal artery itself during the initial diagnostic enhanced CT. Hence, angioplasty using stent placement was performed to promote the recovery of renal function and easily performed through the aortic bare metal stent inside the true lumen. We obtained favourable results in this complicated aortic emergency using the TEVAR technique, although the long-term results of this treatment remain unclear and require continued close follow-up. Conflict of interest: none declared. REFERENCES 1 Shu C, Wang T, Li QM, Li M, Jiang XH, Luo MY et al. Thoracic endovascular aortic repair for retrograde type A aortic dissection with an entry tear in the descending aorta. J Vasc Interv Radiol 2012; 23: 453– 60. Google Scholar CrossRef Search ADS PubMed 2 Nienaber CA, Kische S, Zeller T, Rehders TC, Schneider H, Lorenzen B et al. Provisional extension to induce complete attachment after stent-graft placement in type B aortic dissection: the PETTICOAT concept. J Endovasc Ther 2006; 13: 738– 46. Google Scholar CrossRef Search ADS PubMed 3 Kische S, D'Ancona G, Belu IC, Stoeckicht Y, Agma U, Ortak J et al. Perioperative and mid-term results of endovascular management of complicated type B aortic dissecting using a proximal thoracic endoprosthesis and selective distal bare stenting. Eur J Cardiothorac Surg 2015; 48: e77– 84. Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
European Journal of Cardio-Thoracic Surgery – Oxford University Press
Published: Apr 24, 2018
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