[MO-78] Presentation Awards
Successful Rescue of Acute Visceral Ischemia after Thoracic Endovascular Aortic Repair for Ruptured Type B Aortic Dissection at Proximal Descending Thoracic Aorta
Background: Thoracic endovascular aortic repair (TEVAR) for ruptured aortic dissecting aneurysm is challenging. Complete obliteration of false lumen is crucial to stop exsanguination. Open conversion of aortic graft repair might be mandatory. Compromising true lumen of downstream aorta after TEVAR is seldom if the stent grafts are correctly placed in true lumen of aorta.
Case Report: A 65-year-old male with history of chronic type B aortic dissection was referred to ER due to acute chest/back pain, cold sweating and hypotension. The CT revealed ruptured dissecting aortic aneurysm of descending aorta with massive pleural hematoma. Emergent TEVAR proceeded after 100% confirmation of wire in true lumen. Two aortic stent grafts were placed top-down with Zone 2 proximal landing and T9 distal landing followed by embolization of left subclavian artery. The retrograde flow of false lumen from re-entry of abdominal aorta was obliterated successfully by post-stent ballooning. Acute hepatic/renal failure were noted in the following 12 hours. Emergent CT showed acute true lumen closure of downstream aorta and ischemic bowel. Distal stent graft was extended in hybrid theater and true lumen of abdominal aorta and visceral arterial flow were reassured. The 2nd TEVAR went well and the liver/kidney function returned normal after several days. The pleural hematoma wasn't removed till 10 days later. The patient was discharged without sequelae 40 days after 2nd TEVAR.
Discussion: False lumen rupture of aortic dissection is fatal and difficult in repair especially by endovascular method. Secure proximal and distal landing is crucial to save the life. In this case, plain ballooning to the distal stent might be effective to close false lumen flow near stents temporarily but downstream true lumen was inadvertently compromised. Surgeons omitted this finding initially, but corrected the fault effectively soon enough.
Case Report: A 65-year-old male with history of chronic type B aortic dissection was referred to ER due to acute chest/back pain, cold sweating and hypotension. The CT revealed ruptured dissecting aortic aneurysm of descending aorta with massive pleural hematoma. Emergent TEVAR proceeded after 100% confirmation of wire in true lumen. Two aortic stent grafts were placed top-down with Zone 2 proximal landing and T9 distal landing followed by embolization of left subclavian artery. The retrograde flow of false lumen from re-entry of abdominal aorta was obliterated successfully by post-stent ballooning. Acute hepatic/renal failure were noted in the following 12 hours. Emergent CT showed acute true lumen closure of downstream aorta and ischemic bowel. Distal stent graft was extended in hybrid theater and true lumen of abdominal aorta and visceral arterial flow were reassured. The 2nd TEVAR went well and the liver/kidney function returned normal after several days. The pleural hematoma wasn't removed till 10 days later. The patient was discharged without sequelae 40 days after 2nd TEVAR.
Discussion: False lumen rupture of aortic dissection is fatal and difficult in repair especially by endovascular method. Secure proximal and distal landing is crucial to save the life. In this case, plain ballooning to the distal stent might be effective to close false lumen flow near stents temporarily but downstream true lumen was inadvertently compromised. Surgeons omitted this finding initially, but corrected the fault effectively soon enough.