Aortic Pathology
Angioclub Case
Alex Copelan M.D.
William Beaumont Hospital
October 24, 2013
Chief Complaint
And History Of Present Illness
• CC: Pain between shoulder blades
• HPI: 60 year-old male transferred from outside hospital’s
Emergency Department after awakening earlier in morning
with the sudden onset of severe “piercing” back pain
radiating to his chest. He had never experienced similar
pain. Pain was non-positional and unrelenting. He denied
associated shortness of breath, syncope or pre-syncope,
nausea or vomiting, and numbness or weakness. He denied
illicit drug use.
Other Relevant History
• Past Medical History: Hypertension, Diabetes, Obesity,
Atrial Fibrillation
• Past Surgical History: None relevant
• Social History: 40-year pack per day smoker, chronic
alcoholism, no illicit drugs
• Family History: Hypertension (both parents)
• Medications: Carvedilol, Aspirin (325 mg/day), Metformin
• Allergies: None
Non-Invasive Imaging
(blue arrow)
red arrow
yellow arrow
Non-Invasive Imaging
yellow
arrow
blue arrow
red arrow
green arrow
Diagnosis And Panel Discussion
• Diagnosis: Ruptured thoracic aortic aneurysm, right-sided aortic arch with
aberrant left subclavian artery
• Treatment Options
– Total Aortic Arch Repair
• “Gold Standard” but requires cardiopulmonary bypass, complex circulation
management and significant morbidity
– Thoracic EndoVascular Aortic Repair (TEVAR)
• When implemented alone, mainly utilized for unbranched segment of aorta between
left subclavian and celiac arteries
– Hybrid Aortic Arch Repair
• Includes ascending aorta-based debranching or cervical extra-anatomical bypasses
followed by stent-grafting
• Can be performed in higher-risk patients but not suitable in patients requiring
cardiopulmonary bypass or in those with Type A dissections, and it is an extraanatomical repair
•
Potential Complications of
Intervention
Total Aortic Arch Repair (compared to hybrid procedure)
– Requires cardiopulmonary bypass and circulatory arrest whereas hybrid procedure
does not
– Increased operative time
– Increased blood loss
– Longer hospital stay
•
Endovascular Stent Grafting
– Must have sufficient proximal landing zones to avoid blockage of left or right
common carotid artery and potential stroke
•
Hybrid Procedure
– Avoids cardiopulmonary bypass and circulatory arrest but still has associated
complications
– Renal impairment, respiratory failure, paraplegia, stroke, embolism, endoleak, and
femoral access site complications
Intervention
• Hybrid Procedure: Aortic arch debranching using Dacron branched
graft and endovascular stent grafting
– Median sternotomy and exposure of aorta and great vessels
– 10 mm straight Dacron graft was anastomosed to the body of a 16 mm x 8 mm
bifurcated graft
– 16 mm portion of the graft was anastomosed end-to-side to the ascending aorta
– One limb of the graft was left long and anastomosed end-to-end to the right
common carotid artery
– Second limb of the graft was anastomosed end-to-side to the subclavian artery
– Third limb of the trifurcated graft did not lie smoothly, therefore, a section of
this was divided and anastomosed end-to-end to the left common carotid and
then re-anastomosed to the main graft
Intervention
Thoracic Aortography:
•
Debranching and graft
placement in the proximal
ascending aorta (white arrow)
allows for a sufficient landing
zone for stent graft to repair
the diseased aorta without
threatening cerebral blood
flow
• Calibrated pigtail catheter
(blue arrow) placed in
ascending aorta through right
femoral approach and utilized
in order to select appropriate
stent size
• Left subclavian (green arrow),
left carotid (purple arrow),
right carotid (red arrow), and
right subclavian (yellow
arrow)
Intervention
•
•
•
•
•
Lunderquist wire was placed through left femoral approach
Introducer for endovascular prostheses was placed over Lunderquist wire
Distally, a 40 x 15 Gore endovascular prosthesis was placed and then through this proximally a 45
x 20 endovascular prosthesis was placed
Balloon angioplasty (yellow arrow) of stent grafts was performed
Pigtail catheter was re-advanced into ascending aorta and angiography was again performed and
demonstrated patent flow (red arrow) through the grafted vessels without evidence of endoleak
Summary
-60 year-old male presented with “piercing” back
pain radiating to his chest
-Non-invasive imaging demonstrated a ruptured
thoracic aortic aneurysm and right-sided aortic
arch with aberrant left subclavian artery
-Treatment options included total aortic arch repair,
TEVAR, and hybrid procedure
-Patient was ultimately deemed best suited for
hybrid procedure consisting of aortic debranching
utilizing Dacron branched graft and endovascular
stent grafting