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Interdisciplinary team approach for complicated type B aortic dissection with concomitant hematothorax by endovascular stent grafting and left side mini thoracotomy: a case report
© Vollroth et al.; licensee BioMed Central Ltd. 2012
Received: 8 June 2012
Accepted: 23 September 2012
Published: 12 October 2012
Due to high mortality rates in surgical treatment, total endovascular stent grafting has become a promising therapeutic option in patients with acute aortic dissection type B. In our case, a 76- year- old patient with acute ruptured aortic dissection type B and hematothorax achieved concomitant total endovascular stent grafting and left side mini thoracotomy. With moderate neurologic impairment he was discharged from hospital after 20 days.
This case shows that early mortality of live threatening acute aortic dissection type B with hemorrhagic pleural effusion may be reduced by total endovascular stent grafting and concomitant mini thoracotomy.
Currently, there are still different ideas about the management of acute type B aortic dissections. Generally, medical treatment is preferred when there are no life-threatening complications . In contrast surgical intervention for acute type B aortic dissection has been reserved for complications such as aneurismal rupture, end organ malperfusion and failure of conservative management. In such special cases mortality ranges from 25-50% . Endovascular aneurysm repair (EVAR) which was first applied to abdominal aortic aneurysms in the early 1990s and to descending aorta aneurysms later on, has currently achieve the treatment of choice for acute type B dissection . Several studies demonstrated technical feasibility of endovascular approaches even to tackle the difficult clinical scenario of type B dissection [3–5]. However, we suggest that patients may benefit from surgical stand by in the event of acute blood loss or dramatic aortic rupture.
In this report, we present a case of Thoracic endovascular aortic repair (TEVAR) and concomitant left side mini thoracotomy for the treatment of acute type B aortic dissection in a patient with acute hemorrhagic shock due to severe hematothorax.
Simultaneously the left femoral artery was surgically accessed and a transversal arteriotomy was performed. A 5F sheath was inserted percutaneously through the right brachial artery, through which a 5F pigtail catheter was directed for angiographic monitoring of the endovascular graft position. After administering 5,000 units of heparin we inserted the delivery system through the arteriotomy in the left common femoral artery. Valiant Captiva (34-34-200 mm) stent prosthesis was positioned and expanded in order to exclude aneurysm completely. At the end of the procedure, angiography was used to demonstrate the correct location of the stent and regular perfusion of the aorta and its branches.
With moderate inotropic support, the patient was administrated to our ICU. Furthermore the patient received a cerebrospinal fluid drainage system immediately after arriving on ICU. It was used for spinal cord protection within the next 3 days.
The suitable treatment strategy for acute descending aortic dissection has long been a matter of debate and continues to be a challenge . High mortality rates in surgical treatment (25-50%) of complicated acute type B dissections, directed surgeons to search for other treatment modalities. Implementation of endovascular techniques has provided new therapeutic options . Initial series and subsequent multicenter trials demonstrated technical feasibility and a low rate of complications even in high-risk patients with acute type B dissection.
However, treatment of acute aortic dissections by endovascular grafting itself carries some risks. Leakage can occur in approximately 25% of patients. Rarely, the stent graft may not plug the aortic wall adequate and may dislocate. In 8% of patients embolic material may originate from an atherosclerotic basis and corrupt the blood flow of the spinal cord, leading to paraplegia. There is furthermore the risk for abdominal malperfusion. In this situation fenestration of the dissection membrane is recommended in several publications.
The most serious circumstance is rupture of the dissected aorta. In most of these cases the blood loss is very high and occurs into the left pleura. Without sufficient treatment strategies in specialized centres it leads directly to subsequent hemorrhagic shock and highly increased morbidity and mortality. This case illustrates that optimal treatment strategies are necessary to avoid serious complications. In our case, hemorrhagic and pulmonary shock due to ruptured aneurysm requires simultaneous thoracotomy and endovascular stent implantation. While opening the left pleura and release hemorrhagic effusion, stent grafting was performed during sufficient circulation and mechanical ventilation.
Complicated acute type B dissection remains a clinical challenge. Patients with complicated type B dissection and signs of clinical instability at presentation have a high risk of in-hospital mortality. The choice of endovascular stent-graft placement in combination with surgical stand by may offer a strategy to improve in-hospital prognosis.
Written informed consent was obtained from the patient for publication of this report and any accompanying images.
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