A Successful Endovascular Treatment for Complicated Acute Type B Aortic Dissection

Worawong Slisatkorn, Decho Jakrapanichakul, Manop Pithukpakorn, Thanongchai Siriapisith
A 22 year old man presented with severe epigastric pain 11 days ago experienced during sexual activity. He had visited many hospitals and received medication for peptic ulcer, but his pain still persisted. He had no history of abdominal injury, no smoking and no relevant family history. Physical examination showed a tall, thin man with 190 cm. in height, 192 cm. in arm span. BP 130/ 90 mmHg., pulse 90 beats/minute. He had no cardiac murmur, no abnormal visual acuity, mild abdominal tenderness,
more » ... ominal tenderness, no guarding and no rigidity. All peripheral pulses were full. His long fingers can surround his wrist. Blood chemistry did not show any abnormality. Chest X-ray revealed widening of the medias-tinum and CT angiography of his thoracic and abdomen demonstrated a descending aortic dissection extended to the aortic bifurcation. Aortic dissection is characterized by an intimal flap which divides the aortic lumen into true and false lumen (Fig 1-3). The aortic sinus was 4.6 cm. in maximal diameter. Both aortic lumens were persistent with large false channel and compressed true channel. The celiac artery, superior mesenteric artery and right renal artery were taken off from the true lumen except the left renal artery came from the false lumen. No pleural effusion was demonstrated. His clinical features match with Marfan syndrome appearance. The patient was diagnosed acute aortic dissection Stanford type B with visceral malper-fusion. He was decided to operate because of the complicated acute type B dissection. ABSTRACT A young male patient with Marfan syndrome suffered from acute type B aortic dissection with visceral organ malperfusion. The thoracic stent grafting was urgently performed with a successful outcome. This study reports a potential endovascular approach to treat complicated acute type B aortic dissection in a Marfan syndrome patient. Intraoperative transesophageal echocardiography (TEE) was performed and showed the intimal tears at many levels of the descending and abdominal aorta with the major tear at the proximal descending aorta. The true lumen was compressed. An endovascular stent grafting was planned to get rid the proximal communication between true and false lumen and enhance the blood flow to the true lumen. The procedure was accomplished under general anesthesia and the TEE guide. The stent graft was deployed in the true lumen at the proximal descending aorta to close the major tear and to intentionally cover the left subclavian artery. The postoperative angiography revealed an enlarged size of the true lumen with decreased flow in the false lumen. His abdominal symptom gradually improved without left arm claudication and vertebral steal syndrome. At 3 months postoperatively, computerized tomographic angiography (CTA) revealed the patent stent graft occupying in the true lumen and disappearance of the false lumen in the descending thoracic aorta (Fig 4,5). The dissection persisted below the stent graft level and both lumens were perfused. DISCUSSION The acute aortic dissection is an emergent car-diovascular condition. The symptom of severe sudden onset of chest or abdominal pain carry a high index of suspicion. The other symptoms could be from complications of vascular compromise for example syncope, stroke, myocardial infarction, spinal cord ischemia, visceral or limb ischemia. The majority of the patients have a history of hypertension. The connective tissue SIRIRAJ MEDICAL LIBRARY