7.1 

Dissection: Stanford A

A 68-year-old woman spontaneously and suddenly developed severe retrosternal pain during her holiday in Turkey. Without knowing the diagnosis, she flew home 2 dayslater.Computedtomography(CT)scanstakenimmediatelyafterarrivalrevealed a dissection of the ascending aorta, the aortic bow and the descending aorta.

Question 1

How would you classify the aortic dissection?

A.  Stanford A dissection. B.  Stanford B dissection. C.  de Bakey I dissection. D.  de Bakey II dissection. E.  de Bakey III dissection

On the same day, she underwent an emergency operation. The dissected ascending aorta with the entry of dissection was incised in a cardiopulmonary bypass and replaced by a graft using the in-graft technique. The aortic valve was patent and remained in situ. For reconstruction of the aortic root, the sandwich technique was used. Two Teflon strips were placed externally and into the true lumen to reattach the dissected membrane to the aortic wall. The aortic graft was then sutured into the reconstructed aortic root.

B.T. Weis-Müller ( )

Department of Vascular Surgery and Kidney Transplantation, University Clinic of Düsseldorf,

Düsseldorf, Germany

Question 2

Which of the following statements are wrong?

A.  Stanford A dissections should be treated medically.

B.  Stanford A dissections should undergo operation immediately.

C.  Stanford B dissections without ischemic complications should be treated medically. D.  Stanford B dissections require operative intervention immediately.

E.  Stanford A dissections require an aortic stent graft immediately.

The postoperative course was uneventful at the beginning. However, 3 days later, renal function deteriorated and the patient required haemofiltration. Moreover, the patient developed severe hypertension and had to be treated with three different antihypertensive drugs. Contrast CT scans revealed that the right kidney was without function due to an old hydronephrosis, while the left renal artery was probably dissected. Furthermore, the patient developed left leg ischemia and was transferred to our centre. We explored the abdomen via the transperitoneal approach. The pulsation of the left iliac artery was weak due to aortic and left iliac dissection. Infrarenal aorto-iliac membrane resection was performed to restore the blood flow to the extremities. Then the left renal artery was explored; the renal artery dissection was found to extend towards the hilus of the kidney.

Revascularisation was achieved with a saphenous vein interposition graft placed between the left iliac artery and the distal left renal artery (Fig. 7.1).

Question 3

Which of the following statements are correct?

A.  Complications of Stanford A dissection are aortic valve insufficiency and perforation into the pericardium.

B.  Stroke is a typical complication of Stanford B dissection. C.  Paraplegia is a typical complication of aortic dissection.

D.  Most patients with Stanford B dissections die of aortic perforation.

E.  Typical complications of aortic dissection are organ and lower-extremity ischaemia.

The postoperative course was uneventful. The patient recovered promptly from the operative intervention, while renal function and blood pressure improved substantially. Urine production and laboratory findings became normal, and only one antihypertensive drug (a beta-blocker) was necessary to maintain normal blood pressure. The postope­ rative angiography showed a patent iliac-renal interposition graft and normal perfusion of the left kidney (Fig. 7.1). CT scans taken 2 years later displayed a hypertrophic, ­well-functioning left kidney, while the right kidney was small and hydronephrotic (Fig. 7.2).

Fig. 7.1 (a) Left common iliac artery. (b) Left renal artery saphenous vein bypass

Fig. 7.2 Computed tomography (CT) scans taken 18 months after operative intervention show

awell-functioning, hypertrophic left kidney and

asmall, hydronephrotic right kidney. Note the dissected but non-dilated aorta