Iatrogenic Aortic Coarctation Physiology after Elephant Trunk Procedure for Type A Aortic Dissection
Abstract/Description
Introduction: Surgical management of type A aortic dissections has evolved, with growing adoption of extended aortic repairs into the descending aorta. Despite accumulating experience in complex aortic repairs, morbidity and mortality remain high. We present a case of iatrogenic aortic coarctation post-elephant trunk procedure that was ultimately repaired via a thoracic endovascular aortic repair (TEVAR).
Methods: The patient is a 40-year-old male with a medical history of hypertension and cigarette smoking who presented with acute onset of dizziness, hypotension, acute kidney injury (AKI) (Cr 1.4, baseline 0.9) and type 2 myocardial infarction. Echocardiogram showed severe aortic insufficiency, and CTA evidenced an acute type A0-3 aortic dissection, with a circumferential multi-luminal dissection flap at the aortic arch involving all brachiocephalic vessels and an aneurysmal proximal descending thoracic aorta. An emergent Bentall procedure with total arch replacement and a branched aortic graft in an elephant trunk (ET) fashion was performed. The graft was invaginated and sutured at the proximal descending thoracic aorta.
Results: Postoperative AKI, shock liver, and lower extremity ischemia with monophasic waveforms detected on renal and mesenteric duplex prompted vascular surgery consultation. Repeat CTA showed ET collapse, and an urgent zone 3-4 TEVAR was performed using single right common femoral access, followed by balloon angioplasty at proximal seal zone to prevent endoleak. Post-deployment angiogram showed successful ET graft expansion. On the third day post-TEVAR, paraplegia was evidenced upon sedation wean. Stroke work-up was negative and spinal cord ischemia protocol was initiated, with gradual improvement noted on the next day leading to complete neurological recovery after 6 days. Additionally, renal and hepatic functions normalized on day 4. The patient was discharged on hospital day 22 with pre-discharge CTA showing excellent aortic remodeling.
Conclusion: Aortic coarctation is a rare complication following ET procedure, thus a high index of suspicion is required to differentiate it with other etiologies of postoperative malperfusion. Our study shows that TEVAR is a safe and minimally invasive approach to expand the free-floating aortic graft. Its use to expand collapsed ET graft has not been described.
Faculty Advisor/Mentor
Dr. Animesh Rathore, MD
Faculty Advisor/Mentor Email
AXRATHOR@sentara.com
Faculty Advisor/Mentor Department
Sentara Vascular Surgery
College/School/Affiliation
Sentara
Included in
Iatrogenic Aortic Coarctation Physiology after Elephant Trunk Procedure for Type A Aortic Dissection
Introduction: Surgical management of type A aortic dissections has evolved, with growing adoption of extended aortic repairs into the descending aorta. Despite accumulating experience in complex aortic repairs, morbidity and mortality remain high. We present a case of iatrogenic aortic coarctation post-elephant trunk procedure that was ultimately repaired via a thoracic endovascular aortic repair (TEVAR).
Methods: The patient is a 40-year-old male with a medical history of hypertension and cigarette smoking who presented with acute onset of dizziness, hypotension, acute kidney injury (AKI) (Cr 1.4, baseline 0.9) and type 2 myocardial infarction. Echocardiogram showed severe aortic insufficiency, and CTA evidenced an acute type A0-3 aortic dissection, with a circumferential multi-luminal dissection flap at the aortic arch involving all brachiocephalic vessels and an aneurysmal proximal descending thoracic aorta. An emergent Bentall procedure with total arch replacement and a branched aortic graft in an elephant trunk (ET) fashion was performed. The graft was invaginated and sutured at the proximal descending thoracic aorta.
Results: Postoperative AKI, shock liver, and lower extremity ischemia with monophasic waveforms detected on renal and mesenteric duplex prompted vascular surgery consultation. Repeat CTA showed ET collapse, and an urgent zone 3-4 TEVAR was performed using single right common femoral access, followed by balloon angioplasty at proximal seal zone to prevent endoleak. Post-deployment angiogram showed successful ET graft expansion. On the third day post-TEVAR, paraplegia was evidenced upon sedation wean. Stroke work-up was negative and spinal cord ischemia protocol was initiated, with gradual improvement noted on the next day leading to complete neurological recovery after 6 days. Additionally, renal and hepatic functions normalized on day 4. The patient was discharged on hospital day 22 with pre-discharge CTA showing excellent aortic remodeling.
Conclusion: Aortic coarctation is a rare complication following ET procedure, thus a high index of suspicion is required to differentiate it with other etiologies of postoperative malperfusion. Our study shows that TEVAR is a safe and minimally invasive approach to expand the free-floating aortic graft. Its use to expand collapsed ET graft has not been described.