Disekce hrudní aorty. Kombinace chirurgické a endovaskulární léčby

Souhrn

V naší kazuistice chceme prezentovat kombinaci chirurgické a endovaskulární léčby disekce aorty typu A, jako soudobé a konečné řešení tohoto životohružujícího onemocnění.

Klíčová slova:
disekce aorty – kombinovaná léčba – endoluminální terapie – stentgraft

_INTRODUCTION

Acute dissection of the thoracic aorta is a serious medical condition requiring referral to a specialized center of cardiac surgery. According to the Stanford classification [1] there are two types of aortic dissection: type A, when dissection of the ascending aorta is present and distal involvement of the descending aorta is possible or, type B, when only the descending aorta is involved. Type A aortic dissection without surgical treatment shows a dismal prognosis: 30% of patients with aortic dissection die within the first 24 hours, 50% within 48 hours, and 84% during the first 30 days [2]. Thus in spite of a rather high operative risk of app. 25% [3], type A aortic dissection requires urgent surgical treatment. Concerning the dissection of the descending aorta, in the acute phase, the patient is threatened with visceral malperfusion, chronically with aneurysmatic dilatation of the aorta and rupture. These complications may be eliminated either surgically by replacing the diseased aorta or, with fewer complications, by endovascular treatment with stentgraft implantation.

_{CASE REPORT}

A 53-year-old male patient, except treated arterial hypertension without significant comorbidity, diagnosed with dissection of descending aorta and suspected aortic arch dissection, was referred to our department.

AngioCT revealed dissection of ascending aorta, aortic arch and descending aorta (Fig. 1 A, B). The patient was indicated for urgent surgical treatment.

TEE in OR confirmed diagnosis, revealed haemopericardium and significant (3+) aortic regurgitation of tricuspid aortic valve due to sinotubular junction involvement.

_{PROCEDURE DESCRIPTION}

After cardiopulmonary bypass institution with femoral artery cannulation, we cooled the patient to 24 C. Entry of dissection was found in a typical localization above the non-coronary sinus. We glued the dissected arch and performed distal anastomosis using „open technique“ with 28mm prosthesis. After recannulation into prosthesis, we performed aortic valve resuspension, glued the dissected aorta in sinotubular junction, performed proximal anastomosis, reestablished perfusion, rewarmed the patient, defibrillated the heart and weaned the patient off the cardiopulmonary bypass.

Postoperative TEE revealed competent aortic valve, well perfused arteries of arch, and reentry below the origin of left subclavian artery which fills the false lumen of the arch and descending aorta. On the third postoperative day large left pleural effusion was diagnosed, drainage revealed hemothorax and angio-CT signs of leaking dissected aortic wall at level Th 5-6. Subsequently we implanted a stentgraft Talent Medtronic under skiascopy and TEE control. (Fig. 3)

Control angioCT 6 months after the operation reveals no false lumen or dilatation of arch or descending aorta. (Fig. 2)

_DISCUSSION

Combined surgical and endovascular treatment of acute aortic dissection is perspective method of treatment, especially in case of high-risk patients. Long-term results are not yet known and, besides the issue of stentgraft availability, these may be crucial in wider acceptance of this method. Complex and final treatment decreases mortality and the risk of late complications. The paraplegia with endovascular treatment of acute type B aortic dissection occurs in less than 1–3% of cases [4], while surgical treatment of acute dissection conveys 5–10% risk of paraplegia [5]. The mortality rate of conservative treatment of a type B dissection is about 20% and 35–50% after surgical repair. Thus, both conservative and open surgical treatment in patients with type B dissection is associated with a high mortality. Therefore, minimally invasive treatment like this may be advantageous [6, 7].

TEE control during stentgraft deployment helps to reveal flow in false lumen and simultaneously to confirm the right position and expansion of stentgraft. Combined treatment significantly shortens the length of hospital stay; in the case described, the patient was dismissed home after 14 days.

T. Grus, MD

2^nd Surgical Department of Cardiovascular Surgery

1^st Faculty of Medicine, Charles University in Prague

U Nemocnice 2

120 00 Prague 2

Czech Republic

e-mail: tgrus@seznam.cz