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J Thorac Cardiovasc Surg 2006;132:697-698
© 2006 The American Association for Thoracic Surgery

Brief Communication

Transfemoral stent-graft of distal aortic arch complicated with retrograde dissection

Salvador Torregrosa, MDa,*, Hortensia Montes, MDb, Manuel Pérez, PhDa, Andrés Castelló, PhDa, Daniel Mata, PhDa, Francisco Valera, MDa, Anastasio Montero, MDa

a Department of Cardiac Surgery, Hospital Universitari La Fe, Valencia, Spain
b Department of Vascular Radiology, Hospital Universitari La Fe, Valencia, Spain.

Received for publication December 13, 2005; accepted for publication February 24, 2006.

* Address for reprints: Salvador Torregrosa Puerta, MD, Department of Cardiac Surgery, Hospital Universitari La Fe, Avenida de Campanar 21, 46009-Valencia, Spain (Email: torregrosa_sal{at}gva.es).


Figure 1
Drs Pérez, Torregrosa, Valera, and Montes (left to right)


We report a case of transfemoral stent-graft placement in a patient with type B chronic dissecting aneurysm of distal aortic arch, which was complicated by retrograde dissection but was resolved successfully. We discuss the possible cause of this complication.

Clinical Summary

A 57-year old man with a history of acute thoracic pain 3 years previously was seen in September 2005 with interscapular pain. Computed tomographic scanning revealed a type B aortic dissection with 7.9-cm dilatation of distal aortic arch and proximal descending aorta. Angiography demonstrated that the aneurysm involved the left subclavian artery (Figure 1, A). The patient refused conventional surgery, so we offered endovascular treatment.


Figure 1
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  		Figure 1. A, False-lumen aneurysm of distal aortic arch with primary entry tear involving left subclavian artery. B, Proximal end of endovascular graft is deployed near brachiocephalic artery, and false lumen is excluded.

 
To allow enough proximal landing zone for stent-graft placement, a median sternotomy was performed, and the left common carotid and subclavian arteries were dissected free. After administration of 10,000 IU heparin, a partial occlusion clamp was applied to the ascending aorta, and the body of a 16 x 8-mm Dacron polyester fabric Y-graft was anastomosed to the aorta with 4-0 Prolene (Ethicon, Inc, Somerville, NJ). Subsequently, the left subclavian artery was divided, its proximal stump was sewn with 4-0 Prolene, and its distal part was anastomosed to one of the 8-mm branches of the Y-graft with 5-0 Prolene. A similar procedure was performed with the left common carotid artery (Figure 2, A).


Figure 2
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  		Figure 2. A, Bypass between ascending aorta and carotid-subclavian arteries in preparing for placement of endoluminal stent-graft. B, Management of retrograde ascending aortic dissection interposing 30-mm Dacron polyester fabric graft between aortic root and stent-graft, with brachiocephalic arterial revascularization through trifurcated graft.

 
The next day, in the vascular radiology suite, the endovascular procedure was performed with general anesthesia and cerebrospinal fluid monitoring. The right common femoral artery was dissected free. The true lumen was catheterized under fluoroscopy, and the delivery system was advanced through it up to the ascending aorta. Thereafter, a Zenith TX2 40-mm endovascular graft (Cook Group Incorporated, Bloomington, Ind), 10% oversized, was deployed under fluoroscopic control from the brachiocephalic trunk to the descending aorta at the level of T9. Completion aortography confirmed complete aneurysmal exclusion (Figure 1, B).

Four days later, the patient had acute thoracic pain and arterial hypotension. Echocardiography showed severe aortic regurgitation caused by ascending aortic dissection. The patient was immediately transferred to the operating room. Cardiopulmonary bypass was initiated through the right axillary artery and right atrium. During cooling, the ascending aorta was clamped and sectioned, the previous Y-graft was clamped and deanastomosed, and cold blood cardioplegia was administered through coronary ostia (subsequent doses were administered retrograde every 20 minutes). Afterward, the aortic root was repaired by means of gelatin-resorcin-formalin glue injected into the false lumen and adventitial inversion.1Go When the nasopharyngeal temperature reached 17°C, circulatory arrest was achieved, the brachiocephalic artery was clamped, and antegrade cerebral perfusion was established through the right axillary artery at a rate of 600 mL/min. The brachiocephalic artery was then sectioned and a 10-mm Dacron polyester fabric graft was anastomosed with 5-0 Prolene between the divided end of this artery and the deanastomosed Y-graft. The clamp in the brachiocephalic artery was moved to the proximal end of the new trifurcated graft, allowing full antegrade cerebral perfusion. The aortic arch was transected with visualization of the proximal end of the stent-graft, and a 30-mm Dacron polyester fabric graft was anastomosed with 4-0 Prolene distally to the stent-graft, including the aortic wall, and proximally to the ascending aortic root. Finally, the trifurcated graft was anastomosed to this 30-mm graft with 4-0 Prolene (Figure 2, B). Selective cerebral perfusion and circulatory arrest times were 90 minutes, cardiac ischemic time was 180 minutes, and cardiopulmonary bypass time was 275 minutes. The postoperative course was uneventful and without neurologic complications, and the patient was discharged from the hospital 4 weeks after the last operation. As of this writing, helicoidal computed tomography shows complete false-lumen aneurysmal exclusion.

Discussion

The classic surgical treatment of aortic arch aneurysms is associated with significant morbidity and mortality. New modalities of endovascular stent-grafting have therefore been developed as a less-invasive alternative, with transfemoral stent-grafting the least aggressive.2,3Go Even this treatment, however, is not free of serious complications.4,5Go

After we opened the aorta, we discovered that the proximal end of the stent-graft had not adapted to the concavity of the aortic arch, creating an aortic recess in contact with the blood, where the entry tear was found. We think that the blood systolic kinetic pressure turned into a push in that zone, finally causing an intimal rupture that developed into a retrograde dissection.

We believe that the inability of the transfemoral stent-graft to adapt to the aortic arch curvature was the cause of this complication. We therefore recommend open transaortic stent-grafting for patients with type B chronic dissecting aneurysm involving the distal aortic arch, because of the full adaptability of the graft suture to the aortic arch curvature.2Go

References

  1. Floten HS, Ravichandran PS, Furnay AP, Gately HL, Starr A. Adventitial inversion technique in repair of aortic dissection. Ann Thorac Surg 1995;59:771-772.[Abstract/Free Full Text]
  2. Kato M, Ohmishi K, Kaneko M, Ueda T, Kishi D, Mizushima T, et al. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation 1996;94(9 Suppl):II188-II193.
  3. Drenth DJ, Verhoeven EL, Prins TR, Waterbolk TW, Boonstra PW. Relocation of supra-aortic vessels to facilitate endovascular treatment of a ruptured aortic arch aneurysm. J Thorac Cardiovasc Surg 2003;126:1184-1185.[Free Full Text]
  4. Xu SD, Li ZZ, Huang FJ, Yang JF, Wang XY, Zhang ZG, et al. Treating aortic dissection and penetrating aortic ulcer with stent graft. thirty cases. Ann Thorac Surg 2005;80:864-869.[Abstract/Free Full Text]
  5. Rampoldi V, Trimarchi S, Righini P, Tolva V, Inglese L. Open aortic surgical repair for left hemi-arch stent-graft failure. Ann Thorac Surg 2004;78:1075-1078.[Abstract/Free Full Text]




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