A case report of surgical treatment of acute aortic dissection (DeBakey III B) in association with thoracic aortic aneurysm]

This is a case report of 63-year-old man suffering from DeBakey III B acute dissection in association with thoracic aortic aneurysm. He had been following up for hypertension and thoracic aortic aneurysm. He was brought to the hospital by city ambulance complaining of sudden onset of severe back pain. Emergency operation was carried out. It revealed aneurysm of 90 mm in diameter located just distal to the aortic arch and an intimal tear or entry of the dissection located distal to the left subclavian artery. A low porosity Dacron graft was interposed between the distal aortic arch and middle portion of the thoracic descending aorta using inclusion technique. Systemic circulation was bypassing external iliac vein to artery using pump-oxygenator during aortic clamping. His postoperative course was uneventful. In review of the literature, association of the atherosclerotic aneurysm and acute dissection occurred approximately 5% in the cases of aortic dissection with increasing risk of aneurysmal rupture.     

Endovascular treatment of the descending thoracic aorta.

OBJECTIVES: to report our initial experience with endovascular stent graft repair of a variety of thoracic aortic pathology. DESIGN: retrospective single center study. MATERIAL AND METHODS: between February 2000 and January 2002, endovascular stent graft repair was performed in 26 patients: traumatic aortic isthmus rupture (n=3), Type B dissection (n=11) and descending thoracic aortic aneurysm (n=12). The deployed stent graft systems were AneuRx-Medtronic (n=1), Talent-Medtronic (n=13) and Excluder-Gore (n=12). RESULTS: successful deployment of the stent grafts in the intended position was achieved in all patients. No hospital mortality neither paraplegia were observed. Late, non procedure related, death occurred in four patients (15%). Access artery complications with rupture of the iliac artery occurred in two patients and were managed by iliac-femoral bypass. The left subclavian artery was overstented in seven patients (27%). Only the first patient received a carotido-subclavian bypass. The mean maximal aortic diameter decreased significantly in patients treated for descending thoracic aneurysm. Only one patient had an endoleak type II after 6 months without enlargement of the aneurysm. Complete thrombosis of the thoracic false lumen occurred in all but one patient treated for Type B dissection 6 months postoperatively. Two patients underwent a consecutive stent graft placement, due to a large re-entry tear distal to the first stent graft. CONCLUSIONS: endovascular stent graft repair for Type B dissection, descending thoracic aneurysm and aortic isthmus rupture is a promising less-invasive alternative to surgical repair. Further studies are mandatory to determine its long-term efficacy.     

Successful repair of thoracoabdominal aortic aneurysm secondary to chronic dissection by hybrid therapy comprising surgical visceral reconstruction and dual Inoue stent graft implantation

Crawford type II thoracoabdominal aortic aneurysm (TAAA) secondary to chronic dissection was successfully treated with hybrid therapy comprising surgical visceral reconstruction and dual Inoue stent graft implantation. The proximal single-branched Inoue stent graft effectively sealed the entry located near the left subclavian artery and simultaneously excluded the TAAA, while the distal tubular Inoue stent graft sealed the reentry; thus, the artery of Adamkiewicz was left unexcluded and intact between the two Inoue stent grafts. The visceral arteries were reconstructed using a quadrifurcated retrograde bypass with posterior aortic tunneling and end-to-end distal anastomosis to all four vessels to achieve a curved and smooth configuration.     

Endovascular treatment of arch and proximal thoracic aortic lesions

OBJECTIVE: To analyze at one institution the endovascular treatment for aortic arch and proximal thoracic aortic lesions, categorize open arch reconstruction, and make preliminary recommendations based on pathology (dissection vs aneurysm), and anatomical extent of disease. METHODS: A retrospective review of aortic arch and descending thoracic aortic lesions managed with endovascular treatment between June 2002 and June 2007. RESULTS: Thirty-four patients received endovascular repair for aortic dissection (n = 28) and aneurysm (n = 6). Open supra-aortic transposition or debranching of the great vessels was performed in 14 cases of dissection (50%) and six cases (100%) of aneurysm. In 14 dissections, the entry tear was located in the distal aortic arch, enabling the left subclavian artery to be sealed without reconstruction. The procedures were successful in 33 patients (97.1%); one intraoperative death occurred. Type I endoleaks were found intraoperatively in eight cases. After management with balloon angioplasty and by extending the stent implantation, the endoleaks resolved in four cases and decreased in four cases. One patient with Stanford type A dissection died from an unknown cause 3 months after treatment. The overall survival rate was 94.1% (32/34), and all bypass grafts remained patent during the follow-up period. CONCLUSIONS: Endovascular stent grafting is a safe and effective method for the treatment of aortic arch lesions. Transposition of the supra-aortic great vessels can be effectively combined with endovascular stent grafting to ensure both cerebral blood supply and enough landing area for the stent graft.     

经颈动脉腔内技术重建主动脉弓治疗Stanford A型夹层动脉瘤(附1例报告)

目的探讨血管腔内技术重建主动脉弓治疗升主动脉、主动脉弓病变的可行性。方法2005年,对1例StanfordA型夹层动脉瘤,腔内修复主动脉病变之前做右颈总动脉-左颈总动脉-左锁骨下动脉的旁路术;经右颈总动脉将修改的分叉支架型血管主体放入升主动脉,长臂位于无名动脉。短臂应用延长支架型血管延伸至降主动脉。通过腔内技术重建主动脉弓实现累及升主动脉和主动脉弓主动脉病变的微创治疗。结果腔内修复术后移植物形态良好,血流通畅,病变被隔绝,脑、躯干、四肢循环稳定。无严重并发症。结论该手术方案设计合理、技术可行。可能成为复杂胸主动脉病变新的腔内治疗模式。     

Transcarotid artery endovascular reconstruction of the aortic arch by modified bifurcated stent graft for Stanford type A dissection

A 40-year-old man with Stanford type B dissection underwent his first endovascular repair (EVAR) in April 2004 by Talent thoracic stent graft. He had an uncomplicated recovery and maintained good blood pressure control. However, a new retrograde dissection appeared in September 2004. The new dissection involved his aortic arch and ascending thoracic aorta to the opening of the coronary arteries. To reconstruct the aortic arch, bypasses between the right common carotid artery (RCCA), left common carotid artery and left subclavian artery were performed before endovascular repair. A modified bifurcated Talent stent graft was deployed from the RCCA to the ascending thoracic aorta with a long limb in the innominate artery and a short limb in the aortic arch. A further two pieces of graft were deployed via the common femoral artery. The ascending thoracic aorta and aortic arch were reconstructed completely by the bifurcated stent graft. The final angiography confirmed that there was good stent graft configuration, normal blood flow, and stable haemodynamics. No endoleak or other major complications were encountered. This result indicated that it is possible to reconstruct the aortic arch with a bifurcated stent graft and could be a new endovascular repair model for complex thoracic aortic aneurysm and dissection.     

带膜血管腔内支架植入术治疗Stanford B型胸主动脉夹层 (附29例报告)

目的介绍应用带膜血管腔内支架植入术治疗Stanford B型胸主动脉夹层的方法和效果。方法对29例(男25例,女4例,年龄38~77岁)胸主动脉夹层动脉瘤腔内隔绝术患者的临床资料进行回顾性分析。术前采用CT血管成像(CTA)、磁共振血管成像(MRA)技术或CT对主动脉夹层动脉瘤进行评估,术前穿刺左肱动脉行升主动脉对比剂追踪了解破口的位置及撕裂的范围,所有的患者都在全麻下进行的,术中在数字减影血管造影机监视下经股动脉或髂动脉将带膜支架导入胸主动脉封闭夹层破口。结果29例均成功进行了胸主动脉夹层的血管腔内隔绝术,其中25例使用Talent支架,4例为国产支架。术后主动脉造影证实夹层裂口完全封闭或内漏明显减少,无中转开胸手术,围手术期无死亡及严重并发症发生。术后随访3~29个月(平均15个月),其中21例行CT复查,8例行DSA复查,3例病人在术后2~8个月行心脏瓣膜置换术。结论带膜支架腔内隔绝术是治疗胸主动脉夹层动脉瘤的简便安全而有效的方法,近期疗效好。手术死亡率和并发症发生率低,手术成功率和生存率高。     

Surgical treatment for thoracic aortic aneurysm with aberrant right subclavian artery

We present two operative cases of thoracic aortic aneurysm combined with aberrant right subclavian artery (ARSA). Case 1 was a 71-year-old man with a fusiform-type arch aneurysm. He underwent total aortic arch replacement to reconstruct all 4 arch branches. Case 2 was a 39-year-old man suffering from chronic DeBakey type IIIb dissection. He underwent total descending thoracic aortic replacement for the remaining ARSA. In both cases ARSA was diagnosed preoperatively by reconstructed three-dimensional computed tomography (3D-CT). Both patients followed uneventful postoperative courses with excellent results. 3D-CT is helpful for precise planning of surgical strategy in such cases.     

分支型腔内支架人工血管治疗B型主动脉夹层

目的 应用主动脉-左锁骨下动脉分支型支架人工血管治疗累及左锁骨下动脉的主动脉弓部夹层。方法2004年2月至2005年1月，采用北京裕恒佳科技有限公司制作的血管腔内分支型主动脉支架人工血管治疗主动脉弓部B型夹层病人42例。原发破裂口位于左锁骨下动脉开口远侧2cm以内。分支型支架由主动脉支架和左锁骨下动脉支架组合而成。支架直径较相应支撑部位动脉直径增加15％～20％。治疗在血管造影室进行，分支型支架人工血管经送放器送入动脉，在透视下释放，植入主动脉弓和左锁骨下动脉。结果41例（98％）成功放置分支型支架41只和直筒型可弯曲支架人工血管5只；1例因左锁骨下动脉变形成角未能将送放器送入而改用直筒型支架治疗。夹层破裂口均被封闭，夹层真腔全部恢复正常直径。术后复查2例存在少量内漏。入路动脉无损伤，无死亡病例。术后病人均恢复正常活动。结论主动脉-左锁骨下动脉分支型支架人工血管易使用，适合修复破裂口位于左锁骨下动脉开口旁的主动脉弓部夹层，但长期效果还需进一步观察。     

Endovascular repair of a ruptured thoracic aortic dissection with a right sided aortic arch: A case report

BackgroundEmergency treatment of complex aortic pathology is challenging in the setting of a right-sided aortic arch. We report the successful treatment of a ruptured thoracic aortic aneurysm (TAA) in the setting of a Stanford type B aortic dissection (TBAD) and right-sided aortic arch.Presentation of caseThe patient is a 66-year-old male with chronic kidney disease (CKD) admitted with right sided chest pain and hypotension. Computed tomography angiography (CTA) revealed a 5 cm ruptured TAA in the setting of a TBAD and right-sided aortic arch. The TBAD began just distal to the right common carotid artery and involved the origin of the left subclavian artery (SCA). Using a totally percutaneous approach, a conformable Gore^® TAG^® thoracic endoprosthesis was placed in proximal descending thoracic aorta covering the left SCA. Aside from progression of his pre-existing CKD, the patient had an uneventful recovery. CTA one-month post-procedure revealed a type IB endoleak with degeneration of the distal descending thoracic aorta. To exclude the endoleak, the repair was extended distally using a Medtronic Valiant^® thoracic stent graft. The left subclavian artery was subsequently coil embolized to treat an additional retrograde endoleak. The patient has done well with no further evidence of endoleak or aneurysm expansion.ConclusionRight-sided aortic arch presents challenges in the emergency setting. CTA and post-processing reconstructions are very helpful. While the endoleaks prompted additional interventions, the end result was excellent. This case displays the importance of careful attention to detail and follow-up in these complicated patients.     

The midterm results of stent graft treatment of thoracic aortic injuries

INTRODUCTION AND OBJECTIVES: Several publications document the technical feasibility of stent graft repair of aortic transection. We report our mid-term results of endovascular repair of thoracic aortic transections using covered stent grafts and compare this to a cohort undergoing open repair during the same time period to demonstrate the shift in practice pattern at our institution. MATERIALS AND METHODS: A retrospective review of patients who sustained blunt thoracic transection was undertaken. Medical records were examined to identify the clinical outcome of the procedure, and follow-up CT scans were reviewed to document adequate treatment of the transection. Outcome measures include procedure-related mortality, neurological morbidity, and successful immediate and mid-term coverage of the thoracic false aneurysm and absence of graft migration or endoleak. RESULTS: From July, 2000 to October, 2004, 27 patients were identified with descending thoracic aortic transection at our level I trauma center. Fourteen patients were managed nonoperatively, five patients underwent thoracotomy and direct aortic repair, and eight patients underwent endoluminal stent graft repair. Of the endovascular group (n=8), repairs were performed with stacked AneuRx aortic cuffs (Medtronic, Inc., Minneapolis, MN) (n = 6), a Gore thoracic aortic stent graft (Thoracic EXCLUDER; W.L. Gore, Flagstaff, AZ) (n=1), or a Medtronic Talent thoracic endograft (Medtronic, Inc.) (n=1). Access for stent graft deployment was the common femoral artery (n=2), iliac artery (n=4), or distal abdominal aorta (n=2). Completion arch aortography and postoperative CT scanning confirmed successful management of the aortic transection in each patient. There were no procedure-related deaths, paraplegia, or stroke. Postoperative complications included a brachial artery thrombosis in one patient as well as an external iliac artery dissection and acute renal failure in a second patient for a complication rate of 37.5%. Two patients died as a result of their injuries unrelated to the stent graft repair. Mean follow-up of 16.6 mo has shown no evidence of endoleak or stent graft migration. Of the open repair group (n=5), one patient died in the operating room during attempted aortic repair, and one patient had a postoperative stroke. CONCLUSIONS: Due to technical success and absence of delayed complications including endoleak and graft migration, stent graft repair of traumatic aortic transection has replaced open aortic repair as the primary treatment modality in the multiply injured trauma patient at our institution. The postoperative complication rate observed in this small series tempers the success to some degree, but the severity of the complications compares favorably with those observed in the open repair group.     

Anomalous vertebral artery origins: the first and second reports of two variants

We present two cases of aberrant origins of vertebral arteries. Case 1 is of a patient undergoing evaluation of an infrarenal aortic aneurysm stent graft. Computed tomography (CT) angiogram revealed an aberrant right vertebral artery that subsequently joined a second right vertebral artery that had the typical origin off the right subclavian artery. This represents an unusual anatomic variation not previously reported in the literature. Case 2 is of a patient being evaluated for thoracic aorta injury. CT angiogram of the chest revealed a five-vessel aortic arch with aberrant origin of the bilateral vertebral arteries distal to the left subclavian artery.     

Surgical treatment for thoracic aortic aneurysm with aberrant right subclavian artery

We present two operative cases of thoracic aortic aneurysm combined with aberrant right subclavian artery (ARSA). Case 1 was a 71-year-old man with a fusiform-type arch aneurysm. He underwent total aortic arch replacement to reconstruct all 4 arch branches. Case 2 was a 39-year-old man suffering from chronic DeBakey type IIIb dissection. He underwent total descending thoracic aortic replacement for the remaining ARSA. In both cases ARSA was diagnosed preoperatively by reconstructed three-dimensional computed tomography (3D-CT). Both patients followed uneventful postoperative courses with excellent results. 3D-CT is helpful for precise planning of surgical strategy in such cases.     

Aortic debranching for descending thoracic aortic aneurysm repair by stent grafts

Endovascular repair of a descending thoracic aortic aneurysm may result in covering the ostia of the left carotid or left subclavian artery for proper proximal landing zones, and the celiac artery or superior mesenteric artery ostia in the abdomen for distal landing zones. To prevent possible complications of occluding the ostia of these vessels, the authors performed an innominate to left common carotid and left subclavian artery bypass as the first procedure in one patient. In the second patient they performed an aortoceliac and aortomesenteric bypass before stent graft placement. The stent graft repair of the descending thoracic aortic aneurysm was performed subsequently in both patients. This aortic debranching provides subsequent proper placement of thoracic stent grafts.     

Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations

Clinically, penetrating atheromatous ulceration of the aortic wall may be confused with either symptomatic thoracic aneurysm or classic spontaneous aortic dissection. Aortography and computed tomographic (CT) scanning of the thoracic aorta provide specific diagnostic information which permits one to distinguish this lesion from atherosclerotic aneurysm and classic dissection. Hallmarks of findings on aortography and CT scan include the presence of the ulcer and an intramural hematoma. Since the findings may be disarmingly subtle, the potentially progressive and serious nature of this condition may remain unappreciated. Recognition of the penetrating atheromatous ulcer and distinguishing it from aortic dissection arising just distal to the origin of the left subclavian artery is mandatory. Resection of only a conservative segment of the proximal descending aorta suffices for classic dissection in the upper descending thoracic aorta, but the penetrating aortic ulcer requires graft replacement in the area of the ulcer and intramural hematoma.     

Surgical treatment for giant ascending aorta-arch aneurysm coexisted with DeBakey type II dissection on elderly women: report of a case

A 78-year-old woman was admitted to our hospital after computed tomography (CT) had revealed in her the presence of a giant ascending aorta-arch aneurysm. This aneurysm was about 8 cm in diameter and associated with DeBakey type II dissection. Aortography showed the same condition as the CT view with the entry on the ascending aorta. The ascending aortaarch was replaced with a Hemashield 24 mm, by using deep-hypothermic selective cerebral perfusion and the open distal method. There were no complications during her peripostoperative state and no evidence of leakage and remnant dissection on CT and aortography. This is a rare case in which thoracic aortic aneurysm coexisted with dissection. In this case of severe atherosclerosis, deep-hypothermic selective cerebral perfusion and the open distal method provided effective treatment.     

Staged hybrid repair using telescoped stent graft fixation for aortic arch and descending aortic aneurysms

Staged repair of extensive thoracic aortic aneurysms is complicated, with a high incidence of interval rupture between stages. We describe the systematic staged hybrid procedure of a previous endovascular repair of a descending aortic aneurysm and open surgical repair of an aortic arch aneurysm. In the second-stage arch repair, the stent graft was easily retracted and fixed, without dissection, around the aortic arch aneurysm distal side. Extensive thoracic aortic aneurysms were managed without interim rupture or neurologic deficits. This approach avoided the potential for interim rupture because recovery from the first-stage endovascular repair was shorter than that from open repair.     

Staged Thoracic and Abdominal Aortic Aneurysm Repair Using Stent Graft Technology and Surgery in a Patient with Acute Renal Failure

2 ) angiography identified a saccular thoracic aortic aneurysm, right renal artery stenosis, left renal artery occlusion, an infrarenal aortic aneurysm, celiac artery, and inferior mesenteric artery (IMA) orificial stenoses. Via an anterior retroperitoneal approach, bilateral renal artery thromboendarterectomy, infrarenal aortic aneurysmectomy, and IMA reimplantation were performed. The patient's tortuous iliac arteries were straightened to permit future passage of a thoracic stent graft by mobilizing the aortic bifurcation and anastomosing it to a Dacron graft within 4 cm of the renal vessels. Two weeks later, a stent graft was placed via a femoral incision utilizing CO₂ angiography, successfully excluding the saccular thoracic aneurysm. Recovery from both procedures was quick, with rapid return of renal function, and alleviation of the hypertension. At 8 months follow-up, his renal arteries and aorta are patent.     

Early and mid-term results of endovascular treatment of thoracic aorta diseases: a single-center experience

We conducted an analysis to assess early and mid-term outcomes of patients after thoracic endovascular aortic repair (TEVAR) for type B thoracic aorta dissection, descending thoracic aneurysm, or traumatic aortic transection. From January 2016 through December 2018, twenty-seven patients (23 male, 4 female, mean age of 57 years) affected by type B dissection (n = 13 [48.2%]), thoracic aneurysm (n = 9 [33.3%]), and post-traumatic aortic isthmus rupture (n = 5 [18.5%]) were treated using TEVAR with and without left subclavian artery revascularization. All procedures were performed in a hybrid operating room using general (n = 12) or regional (n = 15) anesthesia. A combined brachial artery and bilateral femoral artery access was used in all patients. To achieve adequate proximal thoracic aorta landing zone length, coverage of the left subclavian artery with proximal endovascular plug occlusion was performed in 17 patients (62.9%); including 4 patients undergoing carotid–subclavian artery bypass before TEVAR stent-graft deployment. Primary procedural success rate was 96.3%; 1 patient had a Type Ib endoleak that was treated by distal stent graft extension. Four adverse outcomes occurred in the immediate postoperative period, including 2 cases of left upper arm acute ischemia (7.4%), ischemic stroke (3.7%), and asymptomatic iliac artery dissection (3.7%). During a mean follow-up of 18 months, no graft-related deaths or endoleak occurred. One patient developed symptomatic subclavian steal syndrome 1 month after operation and underwent a left carotid–subclavian artery bypass with symptom resolution. One patient died 6 months after TEVAR due to neoplasm. Our experience indicates TEVAR is a safe and less invasive alternative to open surgery for a spectrum of thoracic aorta diseases, especially for urgent conditions and in patients with high-risk surgical comorbidities.     

Left subclavian artery management in endovascular repair of thoracic aortic aneurysms and aortic dissections

PURPOSE: The purpose is to report our experience and revise our previously published results in endovascular repair of short-necked thoracic aortic aneurysms or aortic type B dissections, in which the left subclavian artery (LSA) was occluded by the stent graft intentionally.METHODS: Seven patients with an aortic type B dissection and three patients who had a thoracic aortic aneurysm were treated endovascularly with stent grafts. In all patients the ostium of the LSA was occluded by the stent graft, only in two patients a primary, prophylactic revascularization of the LSA was performed by transposition to the left common carotid artery (LCA). Two types of stent grafts were used: the Talent (Medtronic) and the Excluder (Gore) stent graft. RESULTS: In all patients the sealing of the entry tear in aortic dissections and the exclusion of existing thoracic aortic aneurysms were achieved. No immediate neurological deficit or left arm ischemia occurred. Nevertheless, during a mean follow-up of 18 months (2 to 31 months) in three patients a second surgical intervention had to be performed due to subclavian steal syndrome, left arm ischemia, or continuing perfusion of the dissected false aortic channel. CONCLUSION: Intentional occlusion of the LSA in stent-graft repair of thoracic aortic diseases seems to be a safe procedure. Close follow-up is needed due to arising subclavian steal syndrome, arm ischemia, or persistent perfusion of the false channel via LSA in aortic dissections after patients' discharge, requiring surgical intervention.