Antegrade Endovascular Aortic Repair After Rupture Of The Descending Aorta In The Setting Of Surgical Repair For Type A Aortic Dissection:

Mohamed Hassan, Kiril Penov , Dejan Radakovic, Nodir Madrahimov, Ivan Aleksic, Khaled Hamouda
University Hospital of Wuerzburg, würzburg, Germany.

BACKGROUND:Acute type A aortic dissection (AAAD) remains a serious cardiovascular disease associated with high in-hospital mortality. Previous studies have reported common causes of in-hospital mortality following surgery for AAAD to include cardiac failure, multiorgan failure, neurological deficit, and aortic rupture. However, few studies have focused on early descending thoracic aortic rupture during surgery for AAAD. We describe herein our experience with patient who survived this fatal complication after successful antegrade endovascular repair.

METHODS:a 58-year-old male presented to the emergency department with a glasgow coma scale of 9 after a syncopal episode at home following a one-day history of generalized malaise and fatigue. Initial findings included severe hypotension, a moderate size pericardial effusion and AAAD on CT angiography (CTA). The patient underwent emergent surgery with a successful Bentall procedure involving replacement of the ascending aorta and aortic arch using frozen elephant trunk in deep hypothermic circulatory arrest. During rewarming period, the perfusonist report a massive volume loss, associated with bloody left pleural effusion. Haemodynamic stabilisation with volume substitution and vasopressors, followed by emergency aortography using a pig tail inserted through the ascending aortic graft indicating the rupture of the descending thoracic aorta. Emergency thoracic endovascular aortic repair TEVAR) was done sealing the rupture with abrupt stabilisation of the patient. The postoperative course was uneventful and the patient was extubated on the second postoperative day without any neurolgical insult.

Results:This case demonstrates the importance of possessing the clinical acumen to quickly identify this fatal complication, and in a patient presenting with rapid accumulating left pleural effusion und volume loss on cardiopulomonary bypass, one should have a high suspicion for an acute aortic rupture, a multidisciplinary effort led to hemodynamic stabilization and performing this life-saving intervention.

CONCLUSIONS: TEVAR may be the game changer in the management of this fatal complication, saving the life of these patients.