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J Thorac Cardiovasc Surg 2008;135:1380-1382
© 2008 The American Association for Thoracic Surgery

Brief Communication

Complicated acute type B aortic dissection involving the arch: Treatment by simultaneous hybrid approach under local anesthesia

Gabriele Iannelli, MDa,*, Mario Monaco, MDa, Luigi Di Tommaso, MDb, Federico Piscione, MD

a Department of Cardiac Surgery, University "Federico II," Naples, Italy
b Department of Cardiology, University "Federico II," Naples, Italy

Received for publication March 20, 2007; accepted for publication April 19, 2007.

* Address for reprints: Gabriele Iannelli, MD, Via Santo Strato, 8, 80123 Naples, Italy. (Email: gabrieleiannelli{at}libero.it).


See related editorial on page 1201

 

We herein report the case of a high-risk patient with complicated acute type B aortic dissection (B-AD) involving the arch up to both common iliac arteries. The patient was treated by a simultaneous hybrid approach accomplished with local anesthesia.

Clinical Summary

A 56-year-old man was admitted to the emergency care unit for chest pain and hypertension because of an acute B-AD involving the distal arch, left subclavian artery (LSA), visceral vessels, and the abdominal aorta up to both common iliac arteries (Go Figure 1). An ascending aortic aneurysm, with a maximum diameter of 42 mm, was also found. An emergency surgical option was considered because of the substantial risk of impending rupture of the false lumen, highlighted by the persistence of chest pain and unresponsive hypertension. Our strategy consisted of a simultaneous hybrid treatment.


Figure 1
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  		Figure 1. Multislice spiral computed tomographic angiogram shows the dissection involving the distal arch, left subclavian artery, visceral vessels, and the abdominal aorta up to both common iliac arteries.

 
Intraprocedural angiography was achieved through the right radial artery, and both radial arterial pressures were monitored. The common carotid arteries were exposed at the neck under local anesthesia, and an 8-mm prosthetic bypass graft (Gelsoft Plus; Vascutek Ltd, Inchinnan, Scotland) was placed between the right and left carotid arteries. To avoid a reflux endoleak, we ligated the left common carotid artery proximal to the bypass graft. An angiogram confirmed patency of the prosthetic bypass graft and satisfactory supply to the circle of Willis. Femoral arterial access was subsequently achieved, also under local anesthesia. The endograft was loaded onto an extra-stiff guidewire and then advanced up to the aortic arch. Mean blood pressure was maintained at 60 mm Hg or higher. The extensive coverage from the origin of the brachiocephalic artery to the celiac axis was performed by 3 cone-shaped Valiant stent grafts (Medtronic Inc, Santa Rosa, Calif) of increasing diameters inserted into the previous stent: the proximal endoprosthesis diameter was 44–40 mm, the intermediate 42–38 mm, and the third 40–36 mm. Each one was 150 mm in length. Completion aortography documented the absence of endoleaks, patency of the brachiocephalic artery and visceral vessels, and overstenting of the left common carotid and LSA arteries, with a gradient of approximately 37 mm Hg in systolic blood pressure between the right and the left arms. No steal phenomena, left arm ischemia, or cerebrovascular accident occurred. The patient was discharged on the fifth postoperative day. At 6 months follow-up, the patient did well, and a computed tomographic scan confirmed patency of the prosthetic bypass graft and complete thromboexclusion of the false lumen (Go Figure 2). Close monitoring of the dissected abdominal aorta and of the ascending aortic aneurysm was planned.


Figure 2
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  		Figure 2. Six months follow-up computed tomographic scan confirmed patency of the prosthetic bypass graft and the complete thromboexclusion of the false lumen.

 
Discussion

To decrease the high risks of mortality and neurologic complications associated with conventional surgery under general deep anesthesia, we opted for endovascular stent-graft repair of B-AD because this offers the advantages of excluding the false lumen and avoiding prolonged proximal aortic clamping and cardiopulmonary bypass.1,2Go

Primary revascularization of the left common carotid artery was required to achieve an adequate proximal landing zone.3Go In our case, a prosthetic bypass graft between the right and left common carotid arteries was accomplished under local anesthesia. Overstenting of the LSA was safely performed without primary revascularization after an accurate evaluation of the supply to the circle of Willis by means of a spiral computed tomographic angiogram and intraoperative conventional arteriography.

No neurologic complications occurred despite the extensive coverage of the entire aortic arch and descending thoracic aorta from the brachiocephalic artery orifice to the origin of the celiac axis.

Contemporary studies assess the risk of paraplegia after conventional surgical repair of the descending thoracic aorta to be between 7% and 36%4Go: some authors recommend adjunctive techniques, such as spinal fluid drainage, to prevent paraplegia, whereas others consider such techniques to be superfluous.5Go Otherwise, as reported by a recent meta-analysis on acute B-AD,4Go the endovascular aneurysm repair strategy significantly decreases the risk of paraplegia, between 0% and 3.4% (mean 0.8% ± 0.4%).

An innovative aspect of this technique is the extensive coverage of the arch and entire descending thoracic aorta, achieved under local anesthesia. No case to date has been reported on the simultaneous hybrid treatment of acute B-AD without general anesthesia.

Close monitoring of the dissected abdominal aorta and of the ascending aortic aneurysm is recommended. This hybrid approach does not preclude the possibility of a secondary endovascular aneurysm repair of the infrarenal abdominal aorta or conventional surgery of the ascending aortic aneurysm if and when required.

This technique offers the option of less invasive treatment to a greater number of patients with severe thoracic aortic disease who would otherwise be exposed to the high risk of conventional surgery, cardiopulmonary bypass, and general deep anesthesia.

References

  1. Trimarchi S, Nienaber CA, Rampoldi V, Myrmel T, Suzuki T, Bossone E, et al. IRAD Investigators Role and results of surgery in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation 2006;114(1 Suppl):I357-I364.[Medline]
  2. Dietl CA, Kasirajan K, Pett SB, Wernly JA. Off-pump management of aortic arch aneurysm by using an endovascular thoracic stent graft. J Thorac Cardiovasc Surg 2003;126:1181-1183.[Free Full Text]
  3. Criado FJ, Clark NS, Barnatan MF. Stent graft repair in the aortic arch and descending thoracic aorta: a 4-year experience. J Vasc Surg 2002;36:1121-1128.[Medline]
  4. Eggebrecht H, Nienaber CA, Neuhauser M, Baumgart D, Kische S, Schmermund A, et al. Endovascular stent-graft placement in aortic dissection: a meta-analysis. Eur Heart J 2006;27:489-498.[Abstract/Free Full Text]
  5. Sullivan TM, Sundt 3rd TM. Complications of thoracic aortic endografts: spinal cord ischemia and stroke. J Vasc Surg 2006;43(Suppl A):85A-88A.[Medline]

Related Article

Treatment of acute type b aortic dissection: New and improved?
R. Scott Mitchell
J. Thorac. Cardiovasc. Surg. 2008 135: 1201. [Extract] [Full Text] [PDF]



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 J. Thorac. Cardiovasc. Surg.Home page
R. S. Mitchell
Treatment of acute type b aortic dissection: New and improved?
J. Thorac. Cardiovasc. Surg., June 1, 2008; 135(6): 1201 - 1201.
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