Endovascular stenting of a chronic ruptured type B thoracic aortic dissection, a second chance: a case report
© Arshad et al; licensee BioMed Central Ltd. 2008
Received: 25 July 2007
Accepted: 07 February 2008
Published: 07 February 2008
We aim to highlight the need for awareness of late complications of endovascular thoracic aortic stenting and the need for close follow-up of patients treated by this method.
We report the first case in the English literature of an endovascular repair of a previously stented, ruptured chronic Stanford type B thoracic aortic dissection re-presenting with a type III endoleak of the original repair.
Endovascular thoracic stenting is now a widely accepted technique for the treatment of thoracic aortic dissection and its complications. Long term follow up is necessary to ensure that late complications are identified and treated appropriately. In this case of type III endoleak, although technically challenging, endovascular repair was feasible and effective.
Medical therapy has been the mainstay of treatment for uncomplicated Stanford type B aortic dissection for many years . However, more recently, endovascular aortic stenting of dissecting thoracic aneurysm has also become a well recognised treatment option . Ongoing studies are currently investigating the long-term safety and efficacy of this technique. The complications of thoracic aortic stenting are also well recognised and graft perforation following endovascular stenting is a known entity [3, 4]. The best treatment modality for the treatment of these complications remains controversial. We report the first case in the English literature of an endovascular repair of a previously stented, ruptured chronic Stanford type B aortic dissection. Our report highlights both the need for awareness of the late complications of endovascular thoracic aortic repair as well as the feasibility of re-stenting in this difficult scenario.
An 82-year-old man, who had previously undergone the first successful endovascular repair of a ruptured chronic type B dissection, presented to us again five years after his first procedure .
His original diagnosis of a Stanford type B aortic dissection had been made in 1994. He was initially managed medically with antihypertensive medication alone, however seven years later, he suffered sudden collapse and chest pain. A ruptured false lumen thoracic aneurysm was diagnosed by spiral computed tomographic angiography (SCTA). The aortic dissection extended distally from the left subclavian artery to the left common iliac artery. The coeliac axis appeared to have a common origin from both the true and false lumens, whereas the left renal and inferior mesenteric arteries originated from the false lumen.
He was deemed to be unsuitable for open surgery due to significant medical co-morbidity, including atrial fibrillation, ischaemic heart disease and chronic obstructive airways disease so therefore endovascular treatment of his condition was undertaken . The challenge was to exclude the rupture while maintaining perfusion of his gut and kidneys. This was undertaken using a total of four Gore Excluder endografts (WL Gore & Associates, Flagstaff, Ariz.). This has been previously described .
After a stormy post-operative course, he was discharged home with regular clinical and radiological follow-up, but after two years he declined to attend further review.
The initial plan was to perform re-stenting on an urgent basis meanwhile optimising his general medical condition. However, on the third day of admission his condition deteriorated suddenly as he became hypotensive and confused. A decision was made with the patient & his family to perform immediate re-stenting of the thoracic aorta as an emergency.
The patient's postoperative recovery was complicated by postoperative pneumonia requiring intravenous antibiotics. Despite supportive treatment he eventually succumbed on the ninth postoperative day to this respiratory complication.
We believe that this case was the first example of endovascular repair of a leaking, previously stented chronic type B ruptured aortic dissection. Similar graft failures have been documented, although these have either been treated medically or surgically by median sternotomy and open repair [6, 7].
As endovascular repair of the thoracic aorta becomes more common, it is inevitable that the number of long term complications will increase. This case illustrates the importance of long term follow up even when all appears satisfactory two years post operatively. In this case further follow up had been declined by the patient. An endovascular approach is feasible but can be technically challenging. Careful monitoring of the durability of endovascular repair of ruptured chronic aortic dissection will be needed to determine the role of endovascular repair in this situation.
Written informed consent was obtained from the patient's next of kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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