Arai Akihito, Tabata Mimiko, Takahashi Kenichiro, Izubuchi Ryo, Hayakawa Minako
Department of Cardiovascular Surgery, Yamato Seiwa Hospital, Kanagawa, Japan.
Department of Cardiovascular Surgery, Yamato Seiwa Hospital, Kanagawa, Japan.
Int J Surg Case Rep. 2024 Oct;123:110318. doi: 10.1016/j.ijscr.2024.110318. Epub 2024 Sep 19.
Hemolytic anaemia from graft kinking is a rare complication after aortic surgery, typically treated by graft replacement. This case highlights hemolytic anaemia caused by the interaction of aortic stenosis and a kinked graft, successfully managed with transcatheter aortic valve replacement (TAVR).
A 75-year-old male developed hemolytic anaemia 2 years after total aortic arch replacement for a saccular aneurysm, with a worsening graft kink and aortic stenosis. Phase-contrast MRI confirmed abnormal blood flow at the kink. Due to his frail condition from prostate cancer, TAVR was performed, resolving the anaemia.
Factors contributing to graft kinking include intraoperative graft length determination, natural aortic elongation with ageing, and graft type. To determine the cause of hemolysis, we needed to evaluate whether it was due to the kinked graft, aortic stenosis, or their combined effect. Hemolytic anaemia appeared at a low pressure gradient of 15.5 mmHg across the aortic valve, making it unlikely that the valve alone was the cause of the hemolysis. Using phase-contrast cardiovascular magnetic resonance, we observed abnormally accelerated blood flow caused by aortic stenosis impinging on the kinked graft. Possible causes include an increased pressure gradient at the kink due to accelerated blood flow, as well as physical collisions that may have resulted in shear stress on the red blood cells.
TAVR resolved hemolytic anaemia caused by aortic stenosis and graft kinking after aortic arch replacement. In high-risk patients, less invasive treatment of the primary condition may effectively resolve hemolytic anaemia.
移植血管扭结导致的溶血性贫血是主动脉手术后一种罕见的并发症，通常通过移植血管置换进行治疗。本病例突出了主动脉瓣狭窄与扭结移植血管相互作用引起的溶血性贫血，经导管主动脉瓣置换术（TAVR）成功治愈。
一名75岁男性在因囊状动脉瘤接受全主动脉弓置换术后2年出现溶血性贫血，移植血管扭结和主动脉瓣狭窄情况不断恶化。相位对比磁共振成像证实扭结处血流异常。由于他因前列腺癌身体虚弱，遂进行了TAVR，贫血得以缓解。
导致移植血管扭结的因素包括术中移植血管长度的确定、随着年龄增长主动脉的自然伸长以及移植血管的类型。为确定溶血原因，我们需要评估其是由扭结的移植血管、主动脉瓣狭窄还是它们的共同作用所致。在主动脉瓣跨瓣压力梯度低至15.5 mmHg时出现了溶血性贫血，这使得仅瓣膜本身不太可能是溶血原因。通过相位对比心血管磁共振成像，我们观察到主动脉瓣狭窄撞击扭结的移植血管导致血流异常加速。可能的原因包括血流加速导致扭结处压力梯度增加，以及可能对红细胞产生剪切应力的物理碰撞。
TAVR治愈了主动脉弓置换术后由主动脉瓣狭窄和移植血管扭结引起的溶血性贫血。在高危患者中，对原发疾病进行侵入性较小的治疗可能有效治愈溶血性贫血。
