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J Thorac Cardiovasc Surg 1998;116:171-175
© 1998 Mosby, Inc.

Brief Communication

Endovascular stent-graft repair for acute type a aortic dissection with an intimal tear in the descending aorta

Tsu, Japan

From the Department of Thoracic and Cardiovascular Surgery^a and the Department of Radiology,^b Mie University, School of Medicine, and the Department of Thoracic and Cardiovascular Surgery,^c Nagai General Hospital, Tsu, Japan.

Received for publication Feb. 2, 1998 Accepted for publication March 24, 1998. Address for reprints: Takatsugu Shimono, MD, Department of Thoracic and Cardiovascular Surgery, Mie University, School of Medicine, 2-174 Edobashi, Tsu, Mie 5148507, Japan.

Stanford type A acute aortic dissection is a catastrophic condition that requires emergency operation. Recently, the outcome has improved because of advancements in surgical techniques and perioperative management. However, the prognosis in patients with an acute type A aortic dissection with an intimal tear in the descending aorta is poor. Herein, we report a case of an acute type A aortic dissection with a tear in the descending aorta that was treated successfully by endovascular stent-grafting. Endovascular stent-graft placement may be a good alternative to conventional surgery for this subtype of acute type A dissection.

Case report

A 54-year-old man, who suddenly felt severe chest and back pain, was admitted to a satellite hospital of the Mie University. He was treated for an acute myocardial infarction. Cerebral hemorrhage in the left putamen occurred as a result of systemic thrombolytic therapy. Two days after admission, contrast-enhanced computed tomography (CT) revealed a DeBakey type I, Stanford type A, acute aortic dissection. He was referred immediately to the Mie University Hospital for evaluation and treatment. The CT scan demonstrated a pericardial effusion and a dissection from the ascending aorta through the abdominal aorta to the level of the left renal artery (Fig. 1, A). Digital subtraction angiography (DSA) showed an intimal tear in the proximal descending thoracic aorta 1.5 cm distal to the origin of the left subclavian artery (Fig. 2, A). The dissection extended retrogradely to the ascending aorta and the aortic arch. It appeared that conventional surgery with cardiopulmonary bypass would exacerbate the cerebral hemorrhage. Therefore endovascular stent-graft repair was subsequently performed.

View larger version (155K): [in this window] [in a new window]   Figure 1. A, Contrast-enhanced CT scans demonstrating a pericardial effusion and aortic dissection from the ascending aorta through the abdominal aorta. B, Contrast-enhanced CT scans 1 month after the stent-graft repair showing elimination of the false lumen from the ascending aorta through the proximal descending aorta.

View larger version (92K): [in this window] [in a new window]   Figure 2. A, DSA showing the intimal tear located in the proximal descending thoracic aorta 1.5 cm distal to the origin of the left subclavian artery (arrowhead). B, DSA 1 month after the stent-graft repair confirming no tear from the ascending through the descending thoracic aorta and no leaks from the graft.

One week after stent-graft placement, contrast-enhanced CT scanning revealed that the false lumen from the ascending aorta through the descending thoracic aorta was thrombosed and that the pericardial effusion was decreased in size. One month later, contrast-enhanced CT disclosed total elimination of the false lumen from the ascending aorta through the proximal portion of the descending thoracic aorta, a reduction in the size of the false lumen from the descending thoracic aorta through the abdominal aorta, and enlargement of the true lumen from the ascending aorta through the abdominal aorta (Fig. 1, B ). DSA 1 month after the repair confirmed the absence of tears in the thoracic aorta and leaks from the stent-graft (Fig. 2, B ). The patient was alive and well 3 months after the endovascular stent-graft repair except for right-sided hemiplegia, which had resulted from the cerebral hemorrhage.

Discussion

Recently, the surgical results in acute type A aortic dissections have improved. However, the management of acute type A dissections with intimal tears in the descending aorta is still difficult. Graft replacement of just the ascending aorta for this subtype of acute type A dissection leaves behind the dissection in the aortic arch and the intimal tear in the descending thoracic aorta. This results in a high possibility of rupture of the aortic arch or descending aorta. Therefore most patients with this subtype of acute type A dissection recently have undergone extended aortic replacement (ascending, arch, and proximal descending). However, the operative mortality is still high. ²

In 1994, Dake and coworkers ³ reported the feasibility of endovascular stent-grafting for aneurysms of the descending thoracic aorta. Mitchell and associates ¹ reported good late results with this technique. Our group has reported the effectiveness of endovascular stents in the treatment of acute aortic dissections in an animal model. ⁴ The Stanford group clinically applies stent-grafting in the treatment of aortic dissections and currently in the treatment of acute dissections with obliteration of the true lumen. ⁵ However, stent-graft repair of aortic dissections in the acute phase is not common.

This is the first report of successful endovascular stent-graft repair of an acute type A aortic dissection with an intimal tear in the descending aorta. Completion of the stent-graft repair for this subtype of type A dissection depends on the location of the intimal tear. The distance between the origin of the subclavian artery and the tear is an important determinant of the applicability of this treatment. In our experience, a distance of at least 1.5 cm is needed for the stent-graft placement to be safe. It appears that endovascular stent-grafting is a good therapeutic option in acute type A dissections with intimal tears in the descending aorta, particularly in light of the difficulty of the surgical approach.

References

1. Mitchell RS, Dake MD, Semba CP, Fogarty TJ, Zarins CK, Liddell RP, et al. Endovascular stent-graft repair of thoracic aortic aneurysms. J Thorac Cardiovasc Surg 1996;111:1054-62.[Abstract/Free Full Text]
   
2. Kazui T, Tamiya Y, Tanaka T, Komatsu S. Extended aortic replacement for acute type A dissection with the tear in the descending aorta. J Thorac Cardiovasc Surg 1996;112:973-8.[Abstract/Free Full Text]
   
3. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J  Med 1994;331:1729-34.[Medline]
   
4. Kato N, Hirano T, Takeda K, Nakagawa T, Mizumoto T, Yuasa H, et al. Treatment of aortic dissections with a percutaneous intravascular endoprosthesis: comparison of covered and bare stents. J Vasc Interv Radiol 1994;5:805-12.
   
5. Slonim SM, Nyman U, Semba CP, Miller DC, Mitchell RS, Dake MD. Aortic dissection: percutaneous management of ischemic complications with endovascular stents and balloon fenestration. J Vasc Surg 1996;23:241-53.[Medline]
   

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