Stent Graft Implantation into a False Lumen of a Chronic Type B Aortic Dissection after Surgical Abdominal Aortic Fenestration / 日本心臓血管外科学会雑誌

A 57-year-old man, who had suffered chest, back and right leg pain about 10 years before, underwent CT and was found a chronic type B aortic dissection with an enlarged false lumen and a narrowed true lumen that was occluded at the infrarenal abdominal aorta. A conventional surgical repair seemed to be too high risk considering his comorbidities, thus we chose a staged hybrid repair. First, surgical repair of the abdominal aorta with an abdominal aortic fenestration was performed. Then, one month after the first operation, zone 2 thoracic endovascular aortic repair with left carotid-axillary artery bypass was performed. At the second operation, the stent graft was purposely deployed from zone 2 into Th12 level of a false lumen through the fenestration followed by coil embolization of a true lumen just distal to the entry tear. The postoperative course was uneventful and he had no complications at 6 months follow-up. Deploying stent graft into a false lumen could be a feasible option in case deploying into a true lumen is not suitable if the anatomical condition permits.

Advances in the effects on false lumen thrombosis after the endovascular treatment of aortic dissection and its intervention strategies / 中华外科杂志

Aortic dissection is a urgent and dangerous disease, and the endovascular treatments can cure it in an effective and efficient way. As an important indicator of aorta remodeling, false lumen thrombosis is related to the prognosis of aortic dissection after endovascular treatment. The relationships among false lumen thrombosis after endovascular treatment and prognosis of aortic dissection, and the clinical techniques that can promote the false lumen thrombosis are reviewed in this paper. The aim is to promote a comprehensive evaluation of aorta remodeling.

Residual False Lumen Rupture Possibly Triggered by Chest Compression after Reparative Surgery for Type A Aortic Dissection / 日本心臓血管外科学会雑誌

Several complications of cardiopulmonary resuscitation have been reported. Herein we reported a rare case of rupture in a false lumen immediately following chest compressions. A 79-year-old woman underwent a graft replacement surgery of acute Stanford type A aortic dissection. On POD 6 she developed cardiopulmonary arrest from suffocation by phlegm. She was immediately resuscitated with chest compressions, although bloody discharge from the left chest drainage tube increased. A rupture was detected by contrast enhanced computed tomography scan in the false lumen of the descending aorta. There was a risk of post-resuscitative encephalopathy ; therefore, conservative treatment, such as blood transfusion, hemostatic administration and therapeutic hypothermia, were performed. After rewarming the patient, she recovered consciousness without any neurological abnormalities. We should bear the possibility in mind that chest compression carries the risk of residual false lumen rupture.

Perioperative outcomes and early closure rate of false lumen of type A aortic dissection patients with different proximal and distal tear size ratio / 中华胸心血管外科杂志

Objective To retrospectively analyze perioperative and early outcomes after Sun's procedure of type A aortic dissection patients with different tear size ratia.Methods To retrospectively analyze the general information of 120 patients with acute Stanford type A aortic dissectiontreatedin our center from November 2014 to December 2016.Patients were divided into three group according to proximal and distal tear sizeratio(PDTSR):35 patients in Group A(PDTSR≥2),44 patients in Group B (1/2 ＜ PDTSR ＜ 2)and 41 patients in Group C (PDTSR ≤ 1/2).Retrospectively reviewed the data of perioperativeand follow-up period.Results Preoperative mortality was significantly higher in Group A (37.1％ vs.2.3％ vs.2.4％;P ＜ 0.001).Preoperative morbidity higher in Group A,but there was no significant difference.Ventilator support of duration ＞ 5 days in Group A is significantly higher in Group A (P =0.006).Three-month closure rate of false lumen was higher in Group A (85.0％ vs.65.0％ vs.72.7 ％,P =0.263).Proximal tear significantly larger than distal tear was found associated with preoperative death in logistic regression analysis.Conclusion Acute type A aortic dissection patients with larger proximal tear size need more urgent surgery to fix the dissection.Sun's procedure was an effective way to cure type A aortic dissection,while patients with relatively larger distal tears need more strict postoperative follow-up.

Endovascular Treatment for Ruptured Chronic Type B Dissecting Aneurysm Using the Candy Plug Technique / 日本心臓血管外科学会雑誌

<p>We report a case of ruptured chronic type B aortic dissecting aneurysm that was successfully treated with the Candy plug technique to exclude a false lumen. A 57-year-old man had undergone abdominal fenestration for complicated acute type B aortic dissection previously. He then underwent debranching TEVAR for an impending rupture because of a dilated thoracic aortic dissecting aneurysm in 2014. After one year, the aneurysm was ruptured because of continuous distal flow of the false lumen. We performed TEVAR using the Candy plug technique, and he was discharged on the 11th postoperative day. The false lumen diameter was reduced. TEVAR using the Candy plug technique for chronic type B aortic dissection was thought to be useful in high-risk patients, but we need more careful observation.</p>

Early Postoperative Descending Aortic Rupture Following Ascending Aorta Replacement for Acute Type A Aortic Dissection / 日本心臓血管外科学会雑誌

We report the findings in an 82-year-old man diagnosed with acute type A aortic dissection. Computed tomography scan showed that the primary entry site was located in the ascending aorta. This finding was confirmed intraoperatively, and emergency ascending aorta replacement of ascending aorta was performed. He subsequently died on postoperative 7 day due to descending aortic rupture. During autopsy, another entry site was found at the root of the brachiocephalic trunk with a patent false lumen, which might have led to the descending aortic rupture.

Chronic Type B Aortic Dissection Associated with Disseminated Intravascular Coagulopathy : The Risk of a Patent False Lumen in the Chronic Phase / 日本心臓血管外科学会雑誌

Patients with chronic type B aortic dissection usually require surgical repair due to aortic dissection-related complications, whereas those with uncomplicated type B acute aortic dissection can usually be managed with medical therapy. Disseminated intravascular coagulopathy (DIC), as well as aortic enlargement, visceral or limb ischemia and recurrent dissection, has been reported as one of the rare complications of type B aortic dissection which require surgical treatment in the chronic phase. DIC is a severe complication which can result in catastrophic events such as gastrointestinal and cerebral bleeding. The management of DIC as a complication of chronic aortic dissection is still controversial, as medical treatment involving anticoagulants and the supplementation of coagulation factors via a transfusion of fresh frozen plasma is not completely reliable. Surgical treatment to close a false lumen can be corrective, but carries the risk of excessive bleeding due to DIC. We report a patient with chronic type B dissection with a patent false lumen complicated by overt DIC. This patient had frequent occurrences of purpura on the upper and lower extremities. Contrast computed tomography in the late phase showed stagnation of contrast medium in the thoracic false lumen, which strongly idicated this false lumen to be the origin of the DIC. We gave the patient a continuous drip infusion of heparin (12,000 U/day) for 1 week before the operation, after which we performed total aortic replacement in order to thrombose the false lumen. His coagulation profile, including platelet count, prothrombin time, international normalized ratio and clinical symptoms improved immediately after the operation. Computed tomography (CT) performed 3 months after the operation showed complete thrombosis and obstruction of the false lumen in the thoracic aorta. The patient is currently well and has resumed routine activities. The continuous infusion of heparin for 1 week was highly effective to improve the coagulopathy in the present case. This case underscores the importance of conducting follow-up to evaluate coagulation-fibrinolysis system function and to measure the aortic diameter by CT in patients with chronic type B aortic dissection with a patent false lumen. Comparison of the early and late phases of contrast-enhanced CT was extremely useful to determine the cause of coagulopathy in this case. Furthermore, the coagulopathy was successfully treated by total aortic arch replacement to close the entry of the false lumen.

Fenestration of the Common Femoral Artery in Patients with Acute Aortic Dissection Combined with Lower Limb Ischemia

Acute aortic dissection is a catastrophic event. Nowadays, the management of aortic dissection can be challenging with performing procedures such as aortic fenestration, stenting and endovascular treatment. While most cases of acute Stanford type A dissection are managed surgically, many cases of acute Stanford type B dissection are treated medically, although open surgery or stent-graft placement is sometimes performed. Patients with Stanford type B dissection may develop vascular complications such as mesenteric or peripheral ischemia, which cannot be managed medically. Fenestration is a procedure for decompressing the hypertensive false lumen by creating a hole in the distal part of the dissection flap and this allows outflow from the false lumen, it relieves branch vessel obstruction, it restores the flow to the ischemic organ and it reduces the risk of extension or rupture of the dissection. Urgent revascularization is required to correct mesenteric and renal ischemia and to restore distal perfusion if there is rest pain and ischemia signs at the lower extremity. We report here on a case of successful surgical fenestration of an acute aortic dissection for relief of lower limb ischemia, and we utilized a transfemoral artery to puncture the obstructed intimal flap.