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J Thorac Cardiovasc Surg 2008;135:1390-1392
© 2008 The American Association for Thoracic Surgery
Brief Communication |
Departments of Cardiothoracic and Vascular Surgery, St George's Hospital, London, United Kingdom
Received for publication December 17, 2007; revisions received January 23, 2008; accepted for publication February 2, 2008. * Address for reprints: Marjan Jahangiri, FRCS, Department of Cardiac Surgery, St George's Hospital Medical School, Blackshaw Rd, London SW17 0QT, United Kingdom. (Email: marjan.jahangiri{at}stgeorges.nhs.uk).
Stent graft placement under direct vision has previously been described during surgical repair of type A aortic dissection to manage further entry flaps or dissection of the descending aorta.1,2
In these series, stents are deployed in an antegrade fashion with the aim of inducing thrombosis of the false lumen and pre-empting possible future complications that may arise from residual type B dissection. Kubota, Endo, and Sudo3 have described techniques to facilitate the insertion of stents in this manner and make it safer.
We describe the use of retrograde open stent graft placement as a rescue procedure to control significant suture line hemorrhage after open repair of a descending aortic dissection.
A 29-year-old man with Marfan syndrome who had undergone aortic root replacement with a Freestyle prosthesis (Medtronic, Inc, Minneapolis, Minn) and only proximal aortic replacement 2 years previously at another hospital arrived at our emergency department with right hypochondrial pain. Computed tomographic (CT) scans showed a 9-cm infrarenal abdominal aortic aneurysm (AAA) and a 5-cm descending thoracic aorta.
The patient underwent laparotomy, which revealed a ruptured juxtarenal AAA.
A significant pectus deformity associated with Marfan syndrome made it impossible to access the supraceliac aorta. Zenith stents (Cook Inc, Bloomington, Ind) were, therefore, deployed to cover the AAA, both iliac arteries, and the left renal artery.
After this, the patient made satisfactory progress. However, CT scans a week after the operation showed a type I endoleak and a new dissection in the descending aorta. The dissection extended from the level of the pulmonary trunk to just above the previously inserted abdominal stent graft. The diameter of the descending aorta was 5.3 cm and was noted to have an acute "U-bend" just above the diaphragm, rendering endovascular repair difficult. The endoleak was managed with a Palmaz stent (Johnson & Johnson Interventional Systems, Warren, NJ) inserted via the brachial approach, and the dissection of the descending aorta was managed medically. The size of the descending aorta remained stable and the patient was discharged home.
He returned a month after discharge with back pain. CT scans at this point showed progressive expansion of the descending aorta to 6.5 cm associated with a moderate-sized left pleural effusion and a proximal intramural hematoma (
Figure 1). Considering these new findings, we proceeded with open repair of the descending aorta.
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At this point, we believed that repeating the proximal anastomosis through such fragile tissue would not guarantee a secure suture line. We therefore opted to reinforce our existing suture line with an endovascular stent placed under direct vision.
A purse string was made in the Dacron graft (neoaorta). The descending neoaorta was partially occluded with a side-clamp and a 40 x 15-mm Tag Stent (W. L. Gore & Associates, Inc, Flagstaff, Ariz) was inserted via an incision in the purse string. The stent was guided to cross the proximal suture line (distal to the left subclavian artery) using a combination of direct vision, manual palpation, and transesophageal echocardiographic guidance, and then deployed. There was an almost immediate improvement in bleeding, allowing satisfactory hemostasis and chest closure.
The patient made a satisfactory recovery in the early postoperative period. He had signs of a brain stem stroke a week after the operation, which completely resolved spontaneously, and was discharged home 2 weeks later. A CT scan before discharge showed a well-positioned stent (
Figure 2). Subsequent scans have excluded the possibility of an endoleak. The patient will be monitored, particularly for the distal part of the aorta.
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During repair of type A dissection, stenting of the descending aorta has been advocated to avoid possible long-term sequelae of residual dissection,1,2 although the absolute need and benefit of managing the descending aorta in this situation is unclear.4 We have applied this technology in a different but not uncommon surgical situation, namely, that of a difficult bleeding point in the context of poor surgical tissues. This technique is not a substitute for precise surgical suturing, but we found it to be helpful in a situation with uncontrollable bleeding in the presence of fragile tissues.
This case also highlights the importance of eliminating as much aortic tissue as possible at the time of original treatment in patients with Marfan syndrome to avoid future multiple and high-risk interventions.
References
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