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| CASE REPORT |
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| Year : 2023 | Volume
: 4
| Issue : 1 | Page : 61-64 |
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Thoracic endovascular aortic repair in stanford Type B* acute aortic dissection
Manu Gupta1, Pankaj Sharma1, Chiraag Mandal1, Virender Sheorain2
1 Department of Radiodiagnosis, AIIMS, Rishikesh, Uttarakhand, India
2 Division of Vascular and Endovascular Sciences, Medanta Hospital-the Medicity Hospital, New Delhi, India
| Date of Submission | 08-Feb-2022 |
| Date of Decision | 07-Jul-2022 |
| Date of Acceptance | 31-Dec-2022 |
| Date of Web Publication | 26-Apr-2023 |
Correspondence Address:
Dr. Manu Gupta
7 Dev Nagar, Agra Mathura Bye Pass Road, Agra - 282 005, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JME.JME_7_22
How to cite this article:
Gupta M, Sharma P, Mandal C, Sheorain V. Thoracic endovascular aortic repair in stanford Type B* acute aortic dissection. J Med Evid 2023;4:61-4 |
How to cite this URL:
Gupta M, Sharma P, Mandal C, Sheorain V. Thoracic endovascular aortic repair in stanford Type B* acute aortic dissection. J Med Evid [serial online] 2023 [cited 2023 Jun 7];4:61-4. Available from: http://www.journaljme.org/text.asp?2023/4/1/61/370395 |
| Introduction | |  |
Acute aortic dissection (AAD) is one of the most common aortic emergencies. Surgical techniques have more severe complications as compared to endovascular stent grafts which result in less morbidity and mortality. Endovascular interventions for complicated AAD have become more acceptable.
The initial treatment of acute uncomplicated Type B aortic dissection is usually conservative medical management. However, many institutions promote thoracic endovascular aortic repair (TEVAR) for these cases to help reduce complications in the chronic phase of aortic dissection, namely a dissecting aortic aneurysm with an increased risk of rupture that would require surgical treatment.[1]
| Case Report | | |
A 25-year-old male presented to our institution after a road traffic accident, driving a two-wheeler and hit by a tractor. The patient had no known comorbidities nor any known coronary or aortic aneurysm history. In the emergency room, the patient had Glasgow Coma Scale of 15/15, pulse was 110/min and blood pressure was 112/70 mm Hg. Respiration was spontaneous with room air saturation of 98%. There was no loss of consciousness, vomiting or ear-nose-throat bleed. On secondary survey, there was an open both bone fracture of the left leg (Type IIIB). The patient had no focal neurological deficits. Contrast-enhanced computerised tomography thorax and abdomen revealed a Type B dissection extending till the ostia of the left subclavian artery with involvement of the aortic arch [Figure 1] and [Figure 2]. There was no active contrast extravasation. There was also minimal pneumothorax with a lung contusion and a haematoma in the left iliac fossa. In view of this, being an uncomplicated Type B dissection with acute limb or organ compromise, the immediate open fracture was surgically assessed and subsequent TEVAR was planned to prevent complications in the chronic phase of the Type B dissection. | Figure 1: Axial contrast-enhanced CT cut showing intimal flap within aortic arch. CT: Computed tomography
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 | Figure 2: Coronal contrast enhanced CT cut showing intimal flap within aortic arch. CT: Computed tomography
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Thoracic endovascular aortic repair procedure
Graft planning based on the computed tomography (CT) angiography with 3D reconstructions was performed [Figure 3]. The dimension of the aorta at the left subclavian artery was 21 mm and dissection length was approximately 3 cm. The size of the stent graft planned was 21 × 100 mm. Bilateral femoral artery access was required. The left femoral artery was punctured percutaneously and a 6F vascular sheath was inserted. Subsequently, marker pigtail was inserted over Terumo hydrophilic guidewire and aortography was performed which revealed the Type B dissection and dissection length was rechecked using the markers on the pigtail [Figure 4]. Right common femoral artery access was obtained through surgical cut down performed by cardiothoracic and vascular surgery surgeons for introduction of a 21F sheath graft deployment assembly. Lunderquist Extra Stiff Wire was introduced into the right femoral artery access to provide support for stent graft deployment. Tto get a proper proximal landing zone, the left subclavian artery ostia was covered. Pre-deployment angiography of both vertebral arteries showed codominance [Figure 5] and [Figure 6] and left subclavian artery ostia could thus potentially be sacrificed. Post-deployment showed no evidence of any endoleak with delayed filling of the left subclavian artery [Figure 7]. On follow-up, the clinical condition of the patient was stable. There were no focal neurological deficits, no tingling or numbness in the left upper limb or any of the other limbs. The patient was discharged asymptomatically on post-procedure day 2. | Figure 3: Aorta 3D reconstruction for endograft planning. 3D: Three-dimensional
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 | Figure 4: Arch aortogram depicting aortic arch and its branches. Marker pigtail and Lunderquist Extrastiff Wire
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 | Figure 7: Covered stent post-deployment. Lunderquist Extrastiff Wire and marker pigtail also seen in the aortic arch
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| Discussion | | |
Aortic dissection commonly used classifications is Stanford and DeBakey classifications [Figure 8]. Management is tailored depending on the type of dissection [Figure 9]. This case involved descending aorta as well as the aortic arch and is still classified as Stanford Type B or more correctly Stanford Type B* (Type B with aortic arch involvement).[2] | Figure 8: Stanford and Debakey aortic dissection classifications (Aimee Rowe – CC-BY-NC-ND 4.0)
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 | Figure 9: Flowchart showing type of management based on Stanford type of dissection
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In spite of open surgical repair being the gold standard of traumatic aortic dissections involving the aortic arch, TEVAR is a viable minimally invasive option that does not entail thoracotomy and is associated with much fewer days of post-procedure hospital stay. TEVAR obviates the need of aortic cross-clamping, hypothermic cardiac arrest and cardiopulmonary bypass that are essential to open surgery.
Complications following TEVAR for aortic dissection comprise both retrograde Type A aortic dissection (RTAD), stent graft-induced new entry (SINE) and enlargement of the residual false lumen. All of these can cause severe morbidity and even mortality. It is also to be noted that SINE onset is more frequent in TEVAR in the chronic phase than in the acute phase, and stent graft oversizing has been reported as a cause of both RTAD and SINE.[1] This warrants the increasing trend to treat acute Type B uncomplicated dissection with emergent TEVAR.
According to the Society for Vascular Surgery Practice Guidelines, those who needs TEVAR for life-threatening acute aortic syndromes with coverage of the left subclavian artery, its revascularisation should be individualised and addressed expectantly on the basis of anatomy, urgency and availability of surgical expertise.[3] In our patient, simple occlusion of the left subclavian artery during TEVAR was performed to create an adequate proximal landing zone for endograft positioning.
Another procedure specific complication of TEVAR is spinal cord ischaemia, leading to paraparesis/paraplegia. This is related to intercostal arteries supplying anterior spinal arteries being covered by the stent graft. If noted early, elevating MAP and cerebrospinal fluid drainage (approximately 15 mL/h) may help to reverse ischaemia.[4],[5] In our patient, no such features of spinal ischaemia were present.
Our case illustrated the merits of TEVAR in a case of uncomplicated Type B dissection with aortic arch involvement (Stanford Type B*). Furthermore, there is benefit in performing emergent TEVAR over conservative medical management in these cases. Randomised controlled trials and more long-term studies are warranted to look for significant differences in prognosis in between these two groups. TEVAR for aortic dissection is a reliable procedure that should be offered to all patients with traumatic aortic dissection in the acute setting due to its significantly less morbidity and hospital stay to the patient as compared to open surgical repair.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Uchida T, Sadahiro M. Thoracic endovascular aortic repair for acute aortic dissection. Ann Vasc Dis 2018;11:464-72.  |
| 2. | Lempel JK, Frazier AA, Jeudy J, Kligerman SJ, Schultz R, Ninalowo HA, et al. Aortic arch dissection: A controversy of classification. Radiology 2014;271:848-55. |
| 3. | Matsumura JS, Lee WA, Mitchell RS, Farber MA, Murad MH, Lumsden AB, et al. The society for vascular surgery practice guidelines: Management of the left subclavian artery with thoracic endovascular aortic repair. J Vasc Surg 2009;50:1155-8. |
| 4. | Hossain GM, Bashar AH, Hakim ME, Hossain MF, Dey NK, Mamun AA, et al. Thoracic endovascular aortic repair (TEVAR): A case report. Bangladesh Heart J 2019;34:146-50. |
| 5. | Fedorow CA, Moon MC, Mutch WA, Grocott HP. Lumbar cerebrospinal fluid drainage for thoracoabdominal aortic surgery: Rationale and practical considerations for management. Anesth Analg 2010;111:46-58. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
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