Acute Aortic Occlusion Due to Fal-Lumen Expansion After Repair of Abdominal Aortic Rupture in Type B Acute Aortic Disction Hiroshi Yamamoto,Fumio Yamamoto,Hiroshi Izumoto,Keisuke Shiroto,Fuminobu Tanaka, Gembu Yamaura,Mamika Motokawa,and Kazuyuki Ishibashi,Akita,Japan
We describe a patient with aortic occlusion due to fal-lumen expansion after repair of abdom-inal aortic rupture in acute type B aortic disction.A70-year-old man prented to a nearby hospital with vere lower back pain,and was subquently referred to our hospital with a diag-nosis of abdominal aortic rupture.Computed tomography scanning on admission revealed type B aortic disction with concomitant fal-lumen rupture at the level of pre-existing infrarenal abdominal aortic aneurysm.The patient underwent abdominal aortic replacement with the true lumen reconstructed using a bifurcated knitted Dacron graft.On postoperative day2,the patient developed vere lower body ischemia.Computed tomography scanning revealed complete true-lumen occlusion at the renal artery level becau of fal-lumen expansion.The patient underwent open fenestration by opening the bulgingflap with a transver graftotomy distal to the proximal graft anastomosis.After fenestration,the patient developed vere metabolic ,myonephropathic-metabolic syndrome)and died a day later of cardiac arrest resulting from hyperkalemia.Abdominal aortic replacement with true-lumen reconstruction in patients with abdominal aortic rupture in type B acute aortic disction could also lead
to acute aortic occlusion due to re-disction or true-lumen compromi accompanying retrograde prop-agation of fal-lumen thrombosis.This lethal quela after true-lumen reconstruction might be prevented by an adjuvant procedure such as concomitant fenestration.
Abdominal aortic rupture in type B aortic disction is a rare but life-threatening pathology.In a review article dealing with the cau of death in266autopsy cas,Hirst ported that acute or subacute aortic disction which ruptures in the retroperito-neum was found in16of266cas(6.0%).1They also reported that the abdominal aorta or iliac arteries were the most frequent re-entry site in the aortic disction(39/66cas:59.1%),1suggesting that in the abdominal aorta,re-entry(inward tear) rather than rupture(outward tear)is more likely to occur as a condary tear in aortic disction.The intraluminal pressure of a partially thrombod fal lumen has been demonstrated to increa as a result of‘‘blind pouch perfusion’’in a laboratory model of acute type B aortic disction.2Both rupture and re-entry can act as a pressure-relea mechanism relieving the elevated intraluminal pressure of the fal lumen,which may exert an inhibitory effect on fal-lumen expansion.Fal-lumen rupture in aortic disction would require urgent intervention such as replacing the ruptured aorta with a vascular prosthesis or placing an endovascular graft on the rupture site.One difficulty is that if there is no pressure-relea mechanism,the elevated intralu-minal
pressure of the blind-ending fal lumen could result in aortic occlusion(true-lumen collap).We describe a patient with aortic occlusion due to fal-lumen expansion after repair of abdominal aortic rupture in acute type B aortic disction. CASE REPORTS
A70-year-old man prented to a nearby hospital with vere lower back pain,and was referred to
Department of Cardiovascular Surgery,Akita University School of
Medicine,Akita,Japan.
Correspondence to:Fumio Yamamoto,Department of Cardiovas-
cular Surgery,Akita University School of Medicine,Hondo1-1-1,Akita,
010-8543,Japan,E-mail:d.akita-u.ac.jp
Ann Vasc Surg2010;24:951.e1-951.e6
DOI:10.1016/j.avsg.2010.03.003头发容易出油
ÓAnnals of Vascular Surgery Inc.
Published online:May14,2010
951.e1
our hospital with a diagnosis of abdominal aortic rupture.The patient was involved in a traffic acci-dent while driving 7days earlier.Computed tomog-raphy scanning on admission revealed type B aortic disction with concomitant abdominal aortic aneu-rysm and massive retroperitoneal hematoma.It was considered to be fal-lumen rupture of the disct-ing abdominal aorta,which was accompanied by a compresd true lumen and bilateral common iliac arteries (Fig.1).On physical examination,blood pressure was 80/60mm Hg,and cyanotic lower extremities and loss of peripheral arterial pulsation were noted.Laboratory studies disclod the following values:hemoglobin,10.6g/dL;white blood cell count,15,400/m L;rum creatine phos-phokina,115IU/L;rum glutamic oxaloacetic transamina,17IU/L;rum glutamic pyruvic transamina,11IU/L;rum lactate dehydroge-na,176IU/L;and rum C-reactive protein 8.37mg/dL.
The patient underwent emergency operation through a median transperitoneal approach under general anesthesia.Massive hematoma was en in the right retroperitoneal cavity.After systemic heparinization,the abdominal aorta was cross-clamped just below the renal arteries,then both common iliac arteries were clamped,and sub-quently the aorta was trancted at the infrarenal level.We found that the aorta had disction three-fourths of its circumference in the right-posterior,and the aortic disction had distally terminated just proximal to the aortic
bifurcation.
Fig.1.Preoperative computed tomography (CT)images at the levels of the thoracic cavity A,B ,diaphragma C ,superior menteric artery D ,left renal artery E ,infrare-nal artery F ,aortic bifurcation G ,and common iliac arteries H .Aortic disction with concomitant abdominal
aortic aneurysm and massive retroperitoneal hematoma was en.A ruptured fal lumen of the discting abdominal aorta was accompanied by true-lumen obstruction (E,F,G).
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The rupture site was located in the right-sided wall of the aneurysmal fal lumen,but no re-entry was obrved in the flap.The patient underwent abdominal aortic replacement with the true lumen reconstructed (i.e.,the fal lumen occluded)using a bifurcated knitted Dacron graft (16Â9mm;Hemashield Gold,Boston Scientific,NJ).The prox-imal graft anastomosis was placed approximately 5cm below the renal arteries.After the operation,blood perfusion to the lower extremities was recov-ered,and peripheral arteries were well-palpable.Again on postoperative day 2,peripheral artery pulsation was lost,and the skin of the buttocks and both lower extremities became pale,indicating vere lower body ischemia.Computed tomography scanning revealed complete true-
lumen occlusion at the level of the renal arteries due to fal-lumen expansion (i.e.,flap bulging)as shown in Fig.2.Laboratory studies showed a creatine phosphoki-na of 1490IU/L,a rum glutamic oxaloacetic transamina of 60IU/L,a rum glutamic pyruvic transamina of 27IU/L,a rum lactate dehydroge-na of 354IU/L,and a rum C-reactive protein of 25.43mg/dL.An emergent open fenestration was performed under general anesthesia.With a trans-ver graftotomy,we found the flap was bulging and occluding the entire lumen of the aorta.There was no additional fal lumen or flap indicating newly developed aortic disction.By incising the bulging flap and removing fresh thrombus in the fal lumen,sufficient arterial blood flow to the lower body was re-established.After the
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open
Fig.2.Postoperative CT images showing aortic occlusion due to fal-lumen expansion.A round-shaped true lumen A is gradually stenotic B and nearly occluded C by fal-lumen expansion.A flap between the true and fal lumens was obrved at the level peripheral to the
true-lumen occlusion D .The fal lumen was terminated by a blind end with concomitant thrombus E ,and the true lumen was completely occluded with thrombus just below the termination of the fal lumen F .
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fenestration procedure,the patient acutely developed vere metabolic , myonephropathic e metabolic syndrome)and un-derwent continuous hemodiafiltration to control rum potassium ion concentration.However,he died1day after fenestration of cardiac arrest result-ing from hyperkalemia.The patient’s family did not permit an autopsy.
DISCUSSION
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External rupture and peripheral malperfusion are known to be life-threatening complications in acute
type B aortic disction.Mortality after acute type B aortic disction has been reported to be higher in patients with a partially thrombod fal lumen than in tho with fal lumen associating re-entries.This may be related to pressure transmission into the blind-ending fal lumen resulting in fal-lumen rupture or true-lumen collap.2Experi-mental studies have demonstrated that pulsatile perfusion into a lumen with restricted outlet, simulating blind-pouch perfusion,resulted in a significant increa in the mean arterial and dia-stolic pressure compared to a lumen with a less-restricted outlet.3The clinical and experimental studies suggest that,in aortic disction without re-entries,fal-lumen expansion may develop two possible pathologies at any aortic level,fal-lumen rupture,or true-lumen occlusion.Therefore,
the two pathologies must be solved simultaneously for successful results.Preoperative pathology of our patient was external rupture of a fal lumen with concomitant peripheral malperfusion,which may be due to thin wall disruption of the blind-ending fal lumen and collap of the aneurysmal true lumen with mural thrombus,evidenced by the operativefinding demonstrating a wall tear and fresh thrombus in the fal lumen and the old mural thrombus in the true lumen.Although we did not actuallyfind fal-lumen expansion,we consider that the intraluminal pressure of the fal lumen might have contributed to collap of the true lumen.We speculate that the mechanism of external ru
pture of the fal lumen may be related not only to thin wall disruption resulting from aortic wall disction but also to an incread intraluminal pressure of the fal lumen.
Several cas have been reported in terms of abdominal aortic occlusion after graft replacement in a patient with type B aortic disction.Hamaji et al.dealt with a ca of true-lumen collap of the peripheral aorta in a patient who underwent double-barreled distal anastomosis during thoracic aortic replacement for chronic type B disction. They reported that the true-lumen collap occurred3days after surgery becau of elevated intraluminal pressure resulting from lack of a re-entry in the fal lumen.4Also,Takahashi et al.dealt with a ca of abdominal aortic occlusion due to fal-lumen expansion10days after true-lumen reconstruction for impending rupture of abdominal aortic aneurysm in a patient with acute type B aortic disction.5The reports suggest that,in type B aortic disction,fal-lumen expansion resulting from lack of a re-entry may be a high-risk pathology for aortic occlusion at the abdominal level.In our patient,postoperatively,rection of the fal lumen including the rupture site and subquent true-lumen reconstruction caud complete aortic ,true-lumen occlusion),ultimately resulting in lethal peripheral and organ malperfu-sion(Fig.3).Our experience suggests that when reconstructing the true lumen,an additional proce-dure should have been performed to avoid a lethal malperfusion disaster.
Prevention of postoperative aortic , true-lumen occlusion)is a crucial factor to
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reduce Fig.3.Schematic diagram of true-lumen reconstruction just after surgery A and fal-lumen expansion and true-lumen occlusion2days after surgery B.The indicated levels of a,b,c,d,e,and f correspond to the cross-ctional CT images in panels A,B,C,D,E,and F in Fig.2,respectively.F,fal lumen;T,true lumen;G, implanted Dacron graft.boasting
951.e4Ca reports Annals of Vascular Surgery
mortality after true-lumen reconstruction for abdominal aortic rupture in acute aortic disction. True-lumen reconstruction with fenestration is one of the solutions.Since the1990s,aortic fenes-tration has been revisited as a safe and effective procedure for descending aortic disction.Elefter-iades ended a surgical fenestration method under retroperitoneal approach for patients prenting with organ ischemia in chronic descend-ing aortic disction,the procedure of which is prox-imal intimalflap excision after infrarenal aortic tranction,and then distal fal-lumen obliteration with suturing the distalflap to the adventitia,fol-lowed by direct aortic closure or Dacron graft anas-tomosis.6Panneton et al.described,in a similar ,proximal intimalflap excision and Dacron graft anastomosis),acute descending aortic disction,where the anastomosis was constructed with a circular felt strip to reinforce the sutures.7 In our patient,we determined that anastomosis of Dacron graft with the proximal native adventitia after fenestration was not safe becau
the proximal adventitia was very thin and fragile;therefore,we constructed the proximal graft anastomosis by suturing the graft to the proximalflap and adventitia in one layer with a circular felt strip.This procedure, however,resulted in true-lumen occlusion due to proximal fal-lumen expansion.Percutaneous aortic fenestration and stent placement might be effective in opening theflap to resuscitate ischemic organs and extremities if the patient developed fal-lumen expansion after true-lumen reconstruc-tion without fenestration.7-9
Endovascular repair has been preferred as an alternative to open surgical repair for acute aortic disction.10Xu et al.investigated the early and mid-term results of stent-graft implantation(entry occlusion)in63patients with acute type B aortic disction,and reported that complete thrombosis of the fal lumen in the thoracic aorta was achieved in98.4%(62patients)of the cas,and postproce-dural mortality during the follow-up period(1-47 months)was4.8%(three patients).11They per-formed a cond stent-graft implantation before discharge in four patients with a re-entry distal to the implanted stent graft.However,postprocedural mortality rates in patients who underwent endovas-cular repair for acute type B aortic disction with complications including fal-lumen rupture,mal-perfusion,and refractory chest pain have been reported to be21-25%in the early12,13and mid-term13results.The caus of death included cardiac arrest,aortic rupture,multiple organ failure,bowel
this怎么读disturbance,and lower limb ischemia.Hinchliffe et al.were thefirst to report successful endovascular repair of a ruptured chronic type B aortic disction, and stresd that stenting of both entry and re-entry points may be required to induce fal-channel thrombosis.14Endovascular repair for fal-lumen rupture with true-lumen occlusion at the abdom-inal aortic level in type B aortic disction has not been reported and stenting for true-lumen reopen-ing and entry occlusion could potentially be difficult to perform safely.
In conclusion,fal-lumen expansion and resul-tant true-lumen occlusion could lead to a lethal lower limb malperfusion in a patient who has undergone abdominal aortic replacement in abdominal-level fal-lumen rupture of acute type B aortic disction.A surgical strategy to prevent blind pouch formation after rection of the rupture might be required for successful postoperative results in pathologies such as fal-lumen rupture of acute type B aortic disction.
REFERENCES
1.Hirst AE Jr,Johns VJ Jr,Kime SW Jr.Discting aneurysm
of the aorta.A review of505cas.Medicine1958;37: 217-279.
2.Tsai TT,Evangelista A,Nienaber CA,et al.Partial
thrombosis of the fal lumen in patients with acute type B aortic disction.N Engl J Med1999;340: 1539-1545.
3.Chung JW,Elkins C,Sakai T,et al.True-lumen collap
in aortic disction.Part I.Evaluation of causative factors in phantoms with pulsatileflow.Radiology2000;214: 87-98.
4.Hamaji M,Kono S,Matsuda M.Repeated true lumen
collap after repair of descending thoracic aneurysm in chronic type B disction.Gen Thorac Cardiovasc Surg 2008;56:459-461.
5.Takahashi Y,Tsutsumi Y,Monta O,Kohshi K,Sakamoto T,
Ohashi H.Acute ont of paraplegia after repair of abdom-inal aortic aneurysm in a patient with acute type B aortic disction.Interact Cardiovasc Thorac Surg2009;8: 240-242.
6.Elefteriades JA,Hammond GL,Gusberg RJ,Kopf GS,iterator
Baldwin JC.Fenestration revisited.A safe and effective procedure for descending aortic disction.Arch.Surg.
1990;125:786-790.
7.Panneton JM,Teh SH,Cherry KJ Jr,et al.Aortic fenes-
tration for acute or chronic aortic disction:an uncommon but effective procedure.J Vasc Surg2000;32: 711-721.
8.Yamaguchi M,Sugimoto K,Tsuji Y,et al.Percutaneous
呼叫保持
balloon fenestration and stent placement for lower limb ischemia complicated with type B aortic disction.Radiat Med2006;24:233-237.
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9.Husmann MJ,Kickuth R,Ludwig K,et al.Intravascular
ultrasound-guided creation of re-entry sites to improve intermittent claudication in patients with aortic disction.
J Endovasc Ther2006;13:424-428.
10.Dake MD,Kato N,Mitchell RS,et al.Endovascular stent-
graft placement for the treatment of acute aortic disction.
N Engl J Med1999;340:1546-1552.
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