Cardiovascular Journal of Africa: Vol 26 No 6 (November/December 2015)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 6, November/December 2015 e10 AFRICA
Application of thoracic endovascular dissecting
aneurysm repair for secondary type B aortic dissection
Oguz Karahan, Orhan Tezcan, Sinan Demirtas, Ahmet Caliskan, Celal Yavuz
Abstract
Type A aortic dissection is an emergency condition that
requires immediate surgery. Graft replacement of the ascend-
ing aorta is the main treatment for this disorder. However,
after ascending aortic replacement, the dissection flap may
progress to the distal side (to the descending aorta) and a
new intimal tear may develop. In this study, we report on a
66-year-old woman who had a history of ascending aortic
replacement six months earlier. She was admitted to hospi-
tal with a new onset of back pain. Computed tomography
revealed a new dissection tear originating from the distal
side of the subclavian artery orifice. Thoracic endovascular
dissecting aneurysm repair (TEVDAR) was carried out on
the patient. Additional complications were not observed in
the postoperative period. Complete cure was provided and the
patient was discharged on the fourth day after the operation.
TEVDAR may be safe and effective in preventing progression
of the aortic flap and the formation of a new intimal tear in
type A aortic dissections. Optional hybrid interventions could
ameliorate the outcomes in aortic dissection cases.
Keywords: type A aortic dissection, surgery, endovascular inter-
vention, hybrid procedure
Submitted 20/7/15, accepted 25/8/15
Cardiovasc J Afr 2015; 26: e10–e12
DOI: 10.5830/CVJA-2015-067
Aortic dissection (AD) is a life-threatening emergency situation
that progresses rapidly. Early mortality rates are as high as 50%,
even under optimal treatment conditions.1-3 Alternate treatment
approaches may be used according to the specific AD subtype.2
The standard AD classification system used in clinical
practice is Stanford’s classification. This system categorises AD
into two classes, type A and B, according to the presence or
absence of ascending aortic involvement.
Surgical replacement of the ascending aorta is indicated as
the most appropriate curative therapy for Stanford type A AD.
However, type B AD may initially be treated medically, with
subsequent surgery or endovascular intervention.2,3 During the
postoperative period, close monitoring of the progression of
the flap, organ perfusion and other systemic events is critical. A
rigorous postoperative follow up is required if the dissection flap
involves the abdominal aorta or if the dissection has progressed
significantly.4
Failure to closely monitor the disease progression in patients
with type A AD undergoing surgical replacement of the aorta
can result in significant clinical complications, such as secondary
type B AD, as presented in the current case. The use of
supplementary medication or hybrid interventions may improve
the success rate of the initial ascending aortic graft replacement
surgery.
Here, we report on a secondary type B AD patient who
had previously been operated on for a type A AD. Thoracic
aneurysm repair with endovascular graft is usually an elective
procedure, but a dissecting aneurysm of the thoracic aorta is a
more progressive and serious condition. We therefore undertook
thoracic endovascular dissecting aneurysm repair (TEVDAR)
instead of thoracic endovascular aneurysm repair (TEVAR).
The presentation, management and clinical outcomes of the case
are presented in the context of the current clinical literature.
Case report
A 66-year-old woman was admitted to hospital with severe
backache. This patient had undergone ascending aortic
replacement surgery to treat type A AD six months prior to
the presentation (Fig. 1). The medical history of the patient
included hypertension for the past 25 years, nephrectomy due
to nephrolithiasis eight years earlier, polio sequela and a motor
deficit of the left leg.
Her systolic blood pressure was 130 mmHg on the right
arm and 110 mmHg on the left arm. All arterial pulses
were determined by manual examination. Contrast-enhanced
computed tomography revealed a type B dissection flap involving
the left subclavian artery with retrograde progression. The
diameter of the true lumen had narrowed significantly to < 10
mm, and the total diameter (with false lumen) was 43.7 mm
at the widest section (Fig. 2). The peak aortic diameter was
measured at 67.2 mm. We therefore initiated preparation for the
TEVDAR surgery.
The patient underwent surgery under general anaesthesia.
During the operation, an initial exploration of the right common
Medical School of Dicle University, Department of
Cardiovascular Surgery, Diyarbakir, Turkey
Oguz Karahan, MD,
Orhan Tezcan, MD
Sinan Demirtas, MD
Ahmet Caliskan, MD
Celal Yavuz, MD
Case Report