Ishibashi Kazuyuki, Motokawa Mamika
Cardiovascular Surgery, Yonemori Hospital, Kagoshima, JPN.
Cureus. 2019 Jun 27;11(6):e5017. doi: 10.7759/cureus.5017.
Retrograde type A aortic dissection (RTAD) is a severe complication of thoracic endovascular aortic repair (TEVAR). In this regard, we present our unique surgical methods for total arch and descending aorta replacement for RTAD after TEVAR for complicated type B aortic dissection (TBAD). A 52-year-old man with a history of distal arch large aneurysm was diagnosed with TBAD. Because he had sustained chest pain and his aneurysm diameter was 67 mm, TEVAR was urgently performed. After a right axillary-left axillary artery bypass, a stent graft was deployed in the descending aorta via the right femoral artery. Coil embolization was performed in the left subclavian artery. After the condition of the stent graft was checked by angiography, no Type 1 endoleak and backflow from the re-entry was observed. However, seven days after the operation, he experienced chest pain suddenly. Computed tomography (CT) revealed forward blood flow in the descending aorta (type IA endoleak) and thrombosed aortic dissection in the ascending aorta. The distal arch diameter exceeded 70 mm. A decision was taken to immediately perform an operation. Total aortic arch and descending aorta replacement were performed through a median sternotomy with left 5th interspace thoracotomy. The operation was performed under deep hypothermic circulatory arrest, and selective antegrade cerebral perfusion was accomplished. As a result of the exploration of the aortic arch, it was found that the intimal injury by the bare stent caused RTAD. The patient was successfully extubated after the operation and was discharged without any complications. RTAD can present as an early complication after descending stent grafting because of aortic instability or due to the strength of bare stents. Aortic arch and descending aorta replacement after TEVAR via a clamshell incision can be safely performed if RTAD is diagnosed early.
逆行性A型主动脉夹层（RTAD）是胸主动脉腔内修复术（TEVAR）的严重并发症。在这方面，我们介绍了针对复杂B型主动脉夹层（TBAD）行TEVAR术后RTAD的全主动脉弓及降主动脉置换的独特手术方法。一名有远端主动脉弓大动脉瘤病史的52岁男性被诊断为TBAD。由于他持续胸痛且动脉瘤直径为67mm，遂紧急行TEVAR术。在进行右腋动脉-左腋动脉旁路移植术后，通过右股动脉在降主动脉置入覆膜支架。对左锁骨下动脉进行弹簧圈栓塞。在通过血管造影检查覆膜支架情况后，未观察到Ⅰ型内漏及再入口反流。然而，术后7天，他突然出现胸痛。计算机断层扫描（CT）显示降主动脉有正向血流（ⅠA型内漏），升主动脉有血栓形成的主动脉夹层。远端主动脉弓直径超过70mm。决定立即进行手术。通过正中胸骨切开加左第5肋间开胸进行全主动脉弓及降主动脉置换。手术在深低温停循环下进行，并完成选择性顺行性脑灌注。通过对主动脉弓的探查发现，裸支架造成的内膜损伤导致了RTAD。患者术后成功拔管，无任何并发症出院。由于主动脉不稳定或裸支架的强度问题，RTAD可表现为降主动脉覆膜支架置入术后的早期并发症。如果早期诊断RTAD，通过蛤壳形切口行TEVAR术后的主动脉弓及降主动脉置换可以安全进行。
