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| CASE REPORT |
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| Year : 2020 | Volume
: 4
| Issue : 1 | Page : 26-27 |
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Type A aortic dissection after abdominal aortic surgery
Murtaza A Chishti1, Vijay Mohan Hanjoora2, Monish S Raut2, Ashish Sharma1
1 Department of Cardiac Surgery, Artemis Hospitals, Gurugram, Haryana, India
2 Department of Cardiac Anesthesia, Artemis Hospitals, Gurugram, Haryana, India
| Date of Submission | 09-Dec-2019 |
| Date of Acceptance | 28-Feb-2020 |
| Date of Web Publication | 17-Apr-2020 |
Correspondence Address:
Dr. Monish S Raut
Department of Cardiac Anesthesia, Artemis Hospitals, Gurugram, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/hm.hm_80_19
Aortic dissection after open surgical repair of infrarenal aortic aneurysm and after endovascular procedures is a rarely observed complication. We present one such interesting case where vigilant monitoring plays an important role to diagnose aortic dissection early and subsequently manage successfully.
Keywords: Aortic aneurysm, aortic dissection, complication
How to cite this article:
Chishti MA, Hanjoora VM, Raut MS, Sharma A. Type A aortic dissection after abdominal aortic surgery. Heart Mind 2020;4:26-7 |
| Introduction | |  |
Aortic dissection after abdominal aortic surgery is a rare but potentially fatal complication. Inspite of recent advances, the mortality of patients with Type A dissection managed surgically was 26% as compared to 58% in patients not receiving surgery.[1] We present one such uncommon case of Type A aortic dissection after abdominal aortic surgery.
| Case Report | | |
A 75-year-old male presented with abdominal discomfort for few months. Computed tomography scanning revealed a large infrarenal abdominal aortic aneurysm (AAA). He had a history of off-pump coronary artery bypass grafting (OPCABG) surgery 6 months back. Echocardiographic examination was suggestive of left ventricular ejection fraction 55% without any other abnormality. The patient was scheduled for AAA repair surgery. General anesthesia was administered after inserting the right radial arterial cannula for invasive blood pressure monitoring. AAA was replaced by synthetic polytetrafluoroethylene (Gore-Tex) vascular graft. In the postoperative intensive care unit, echocardiography was performed to assess volume status, and it demonstrated ascending aortic dissecting flap reaching up to the arch with no aortic regurgitation [Figure 1]. The patient was shifted to the operating room for emergency ascending aorta and aortic arch replacement surgery. The right carotid artery and right atrium were cannulated after adequate heparinization to institute cardiopulmonary bypass. Under deep hypothermia (18°), ascending aorta and arch was replaced using dacron vascular graft. The postoperative course of the patient remained uneventful. | Figure 1: (a and b) Transesophageal echocardiography showing ascending aortic dissection in the long axis (left upper panel) and short axis view (right upper panel), (c) transesophageal echocardiography showing aortic dissection flap in the aortic arch and right brachiocephalic artery, (d) Transesophageal echocardiography showing blood flow in the true lumen
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| Discussion | | |
Aortic dissection being a dynamic process that may occur anywhere within the aorta often with complications and fatal outcomes.[1]
Aortic dissection after open surgical repair of an aortic infrarenal aneurysm and after endovascular procedures is a rarely observed complication. The proposed mechanism could be an intimal-medial disruption by aortic neck manipulation during the surgery creating the false lumen that can dissect the aorta cranially.[2] Retrograde aortic dissection after endovascular interventions such as thoracic stent grafts has been described in up to 2.4% of cases.[3] Direct wire injury to the thoracic aorta with subsequent antegrade dissection and displacement of an ulcerated, calcified plaque by the stent anchors were considered to be the origin of Type B dissection.[3] Coexisting medical conditions such as large-vessel vasculitis and Sjogren's syndrome can eventually lead to medial degeneration and resulting in aneurysms and dissections.[2]
Aortic dissection after descending thoracic and abdominal aortic surgery and interventions are mostly Type B. Rare case of Type A aortic dissection has been depicted after endovascular stenting of infrarenal AAA. The patient had lower limb paraplegia secondary to malperfusion of the lower limbs because of the dynamic obstruction of endovascular graft caused by the flap of newly developed Type A aortic dissection.[4]
A review of all these anecdotally reported cases brings out the fact that aortic dissection after AAA repair was diagnosed substantially late when the patient had developed some complications. The present case was diagnosed immediately in the postoperative period after AAA repair. Previous OPCABG surgery was a predisposing factor for the ascending aorta aneurysm. Risk of aortic dissection is more in OPCABG as compared to on-pump coronary artery bypass grafting (0.97% vs. 0.04%) Atheromatous plaque, aortic calcification, and side clamping of the aorta during OPCABG surgery are thought to be the main risk factors.[5] Aortic dissection, the great masquerader, is often difficult to suspect and detect. The present case emphasized the importance of vigilant monitoring to diagnose aortic dissection early.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The international registry of acute aortic dissection (IRAD): New insights into an old disease. JAMA 2000;283:897-903.  |
| 2. | Lorenzo LR, Villegas AR, Mestre XM, Gonzalez ZM, Castellote C. Aortic dissection after open repair of an infrarenal aortic aneurysm. Int J Angiol 2009;18:143-6. |
| 3. | Kpodonu J, Preventza O, Ramaiah VG, Shennib H, Wheatley GH 3 rd, Rodriquez-Lopez J, et al. Retrograde type A dissection after endovascular stenting of the descending thoracic aorta. Is the risk real? Eur J Cardiothorac Surg 2008;33:1014-8. |
| 4. | Kim HE, Joo HC. Acute type a aortic dissection causing collapse of previous stent graft. Ann Thorac Surg 2018;105:e221-e223. |
| 5. | Li J, Guan X, Gong M, Wang X, Zhang H. Iatrogenic acute aortic dissection induced by off-pump coronary artery bypass grifting: A case report and review of the literature. Medicine (Baltimore) 2017;96:e9206. |
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