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Aortic Pathology Angioclub CaseAlex Copelan M.D.William Beaumont HospitalOctober 24, 2013Chief Complaint And History Of Present IllnessCC: Pain between shoulder bladesHPI: 60 year-old male transferred from outside hospitals Emergency Department after awakening earlier in morning with the sudden onset of severe piercing back pain radiating to his chest. He had never experienced similar pain. Pain was non-positional and unrelenting. He denied associated shortness of breath, syncope or pre-syncope, nausea or vomiting, and numbness or weakness. He denied illicit drug use. 2Other Relevant HistoryPast Medical History: Hypertension, Diabetes, Obesity, Atrial FibrillationPast Surgical History: None relevantSocial History: 40-year pack per day smoker, chronic alcoholism, no illicit drugsFamily History: Hypertension (both parents)Medications: Carvedilol, Aspirin (325 mg/day), MetforminAllergies: None

Non-Invasive Imaging

Widened Mediastinum

Non-Contrast-Enhanced CT: Regions containing fresher blood (blue arrow) are more radiodense than regions containing older blood (red arrow) and this may provide insight as to the initial sight of hemorrhage. This is known as the sentinel clot sign. There was no hemorrhage extension into the pericardium as demonstrated by the low attenuation of the pericardial fluid (yellow arrow)21 HU40 HU69 HUNon-Invasive Imaging

Contrast-enhanced CT: Eight cm saccular aneurysm (yellow arrow) in the distal aortic arch is identified.

Site of aneurysmal rupture is evident as focal out-pouching of contrast (blue arrow)

Focal hemorrhage identified just anterior to the diverticulum of Kommerell (red arrow)

Mediastinal hematoma is evident (green arrow)

Note the right-sided aortic arch with order of branching vessels: left carotid, right carotid, right subclavian, left subclavian (white arrow) with diverticulum of Kommerell.Diagnosis And Panel DiscussionDiagnosis: Ruptured thoracic aortic aneurysm, right-sided aortic arch with aberrant left subclavian arteryTreatment OptionsTotal Aortic Arch RepairGold Standard but requires cardiopulmonary bypass, complex circulation management and significant morbidityThoracic EndoVascular Aortic Repair (TEVAR)When implemented alone, mainly utilized for unbranched segment of aorta between left subclavian and celiac arteriesHybrid Aortic Arch RepairIncludes ascending aorta-based debranching or cervical extra-anatomical bypasses followed by stent-graftingCan be performed in higher-risk patients but not suitable in patients requiring cardiopulmonary bypass or in those with Type A dissections, and it is an extra-anatomical repairPotential Complications of InterventionTotal Aortic Arch Repair (compared to hybrid procedure) Requires cardiopulmonary bypass and circulatory arrest whereas hybrid procedure does not Increased operative timeIncreased blood lossLonger hospital stayEndovascular Stent GraftingMust have sufficient proximal landing zones to avoid blockage of left or right common carotid artery and potential strokeHybrid ProcedureAvoids cardiopulmonary bypass and circulatory arrest but still has associated complicationsRenal impairment, respiratory failure, paraplegia, stroke, embolism, endoleak, and femoral access site complicationsInterventionHybrid Procedure: Aortic arch debranching using Dacron branched graft and endovascular stent graftingMedian sternotomy and exposure of aorta and great vessels10 mm straight Dacron graft was anastomosed to the body of a 16 mm x 8 mm bifurcated graft16 mm portion of the graft was anastomosed end-to-side to the ascending aortaOne limb of the graft was left long and anastomosed end-to-end to the right common carotid arterySecond limb of the graft was anastomosed end-to-side to the subclavian arteryThird limb of the trifurcated graft did not lie smoothly, therefore, a section of this was divided and anastomosed end-to-end to the left common carotid and then re-anastomosed to the main graftIntervention

Thoracic Aortography:Debranching and graft placement in the proximal ascending aorta (white arrow) allows for a sufficient landing zone for stent graft to repair the diseased aorta without threatening cerebral blood flowCalibrated pigtail catheter (blue arrow) placed in ascending aorta through right femoral approach and utilized in order to select appropriate stent sizeLeft subclavian (green arrow), left carotid (purple arrow), right carotid (red arrow), and right subclavian (yellow arrow) InterventionLunderquist wire was placed through left femoral approachIntroducer for endovascular prostheses was placed over Lunderquist wireDistally, a 40 x 15 Gore endovascular prosthesis was placed and then through this proximally a 45 x 20 endovascular prosthesis was placedBalloon angioplasty (yellow arrow) of stent grafts was performedPigtail catheter was re-advanced into ascending aorta and angiography was again performed and demonstrated patent flow (red arrow) through the grafted vessels without evidence of endoleak

Summary

-60 year-old male presented with piercing back pain radiating to his chest

-Non-invasive imaging demonstrated a ruptured thoracic aortic aneurysm and right-sided aortic arch with aberrant left subclavian artery

-Treatment options included total aortic arch repair, TEVAR, and hybrid procedure

-Patient was ultimately deemed best suited for hybrid procedure consisting of aortic debranching utilizing Dacron branched graft and endovascular stent grafting