7.2 

Dissection: Stanford B

A 54-year-old woman was admitted to another hospital with the provisional diagnosis of a myocardial infarction (MI). She experienced a sudden chest pain. Some hours later, she developed paraesthesia in both legs, which improved spontaneously. Subsequently, she felt abdominal discomfort and developed diarrhoea and vomiting. The patient had been normotensive throughout her life, but now she required five different antihypertensive drugs to stabilise blood pressure. Some laboratory data were abnormal, including leucocytes, transaminases, lactic dehydrogenase and lactate. Duplex sonography and transoesophageal echocardiography revealed an aortic dissection of the thoracic and abdominal aorta beginning distal to the left subclavian artery; blood flow into the visceral arteries and the right renal artery was reduced. Contrast CT scans confirmed Stanford B aortic dissection.

Question 4

What diagnostic methods are involved in acute aortic dissection?

A.  Computed tomography. B.  Magnet resonance imaging. C.  Angiography.

D.  Transoesophageal echocardiography.

The patient was first treated medically with parenteral therapy and antihypertensive drugs (including beta-blockers). Under this management, clinical outcome and laboratory findings improved, but 3 weeks later the patient deteriorated again and developed severe right upper abdominal pain.

She was referred to our hospital for operation. CT scans displayed the aortic dissection and a dissected superior mesenteric artery. The true aortic lumen was very small and partially thrombosed (Fig. 7.3). Abdominal exploration via the transperitoneal approach revealed borderline ischaemia of all intra-abdominal organs due to aortic dissection. The dissection had affected the coeliac trunk, the superior mesenteric artery and the right renal artery. The right upper abdominal pain was caused by an ischaemic cholecystitis. The gallbladder had to be removed. The para-aortic tissue displayed severe inflammation; therefore no fenestration and membrane resection could be carried out. Instead, intestinal and renal blood flow was restored by a 12-mm Dacron graft, which was placed end to side into the left iliac artery and end to end to the coeliac trunk. The superior mesenteric artery was implanted directly into the Dacron graft, while the right renal artery was attached by means of a saphenous vein interposition graft (Fig. 7.4).

Fig. 7.3 Aortic dissection, with a small, partially thrombosed “true” aortic lumen and dissected superior mesenteric artery

Fig. 7.4 Extra-anatomicalreconstructionwithaDacrongraft,whichwasplacedendtosidebetween the left common iliac artery and end to end to the coeliac trunk. The superior mesenteric artery was implanted directly into the graft, while the right renal artery was implanted via the interposition of a saphenous vein. The left renal artery originates from the aorta

Question 5

What techniques are used to restore blood flow to the visceral organs and extremities following ischaemia from aortic dissection? Which of the following statements are wrong?

A.Aortic stent graft.

B.Percutaneous transluminal angioplasty (PTA) of organ and limb arteries and stenting.

C.Aortic fenestration and membrane resection.

D.Cardiopulmonary bypass.

E.Extra-anatomic revascularisation, e.g. axillo-femoral bypass.