CEN Case Reports

EVAR Procedure in Aortic Dissection Stanford type B with End-Stage Renal Disease
on Hemodialysis: a Rare Case Report
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Full Title: EVAR Procedure in Aortic Dissection Stanford type B with End-Stage Renal Disease
on Hemodialysis: a Rare Case Report

Article Type: Case Report

Keywords: aortic dissection, EVAR, hemodialysis, renal failure

Corresponding Author: Jonny Jonny

Indonesia Central Army Hospital
INDONESIA

Corresponding Author Secondary

Information:

Corresponding Author's Institution: Indonesia Central Army Hospital

Corresponding Author's Secondary

Institution:

First Author: Jonny Jonny

First Author Secondary Information:

Order of Authors: Jonny Jonny

Marthias Surya

Terawan Agus Putranto

Order of Authors Secondary Information:

Funding Information:

Abstract: Introduction. Aortic dissection is an emergency condition with various clinical

presentations and high mortality risk [1]. Aortic dissection is related to renal ischemia
accompanied by uncontrolled hypertension [2]. Dissection on hemodialysis patient is
rare, Ounissi et al mentioned that among 7128 hemodialysis patient, the prevalence of
aortic dissection is 0.04% [3]. Death occurs due to late diagnosis, Takeda et al
represent that of 896 death, 5.73% occurs suddenly [4]. Being minimally invasive and
has better outcome, EVAR is a promising procedure for aortic dissection, compared to
surgery and medication. [5,6].

Discussion. High mortality rate is associated with delayed recognition of the condition,
to prevent late treatment, early diagnosis should be made by identifying risk factors
such as uncontrolled hypertension, history of previous heart disease, and specific sign
and symptoms related to aortic dissection. Accompanied with hemodynamic
monitoring, medications aims to lower blood pressure and reduce pain. This case
report is about EVAR procedure for type B aortic dissection with end-stage renal
disease on hemodialysis patient, showing better outcome. Post-EVAR procedure,
chest pain was relieved, blood pressure is controlled with two antihypertension drugs,
and quality of life was improved. EVAR procedure closes the entry point of the false
lumen, so blood entering through the true lumen and dissected area could be resolved.

Conclusion. This case report shows successful outcome of EVAR procedure in aortic
dissection with end-stage renal disease. EVAR is minimally invasive, has fewer
cardiovascular complications, and shows better outcomes, these advantages made
EVAR a promising treatment for type B aortic dissection.

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EVAR Procedure in Aortic Dissection Stanford type B

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2 with End-Stage Renal Disease on Hemodialysis: a Rare Case Report
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4 Number of words in the manuscript: 1572 words
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Marthias Surya1 ,Jonny2, Terawan Agus Putranto3
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8 1. Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia
9 2. Nephrology Division, Department of Internal Medicine, Indonesia Central Army Hospital
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11 3. Interventional Radiology Division, Department of Radiology, Indonesia Central Army Hospital
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ABSTRACT
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16 Introduction. Aortic dissection is an emergency condition with various clinical presentations and high
17 mortality risk [1]. Aortic dissection is related to renal ischemia accompanied by uncontrolled hypertension [2].
18 Dissection on hemodialysis patient is rare, Ounissi et al mentioned that among 7128 hemodialysis patient, the
19
prevalence of aortic dissection is 0.04% [3]. Death occurs due to late diagnosis, Takeda et al represent that of
20
896 death, 5.73% occurs suddenly [4]. Being minimally invasive and has better outcome, EVAR is a promising
21
procedure for aortic dissection, compared to surgery and medication. [5,6].
22
23 Discussion. High mortality rate is associated with delayed recognition of the condition, to prevent late treatment,
24 early diagnosis should be made by identifying risk factors such as uncontrolled hypertension, history of previous
25 heart disease, and specific sign and symptoms related to aortic dissection. Accompanied with hemodynamic
26 monitoring, medications aims to lower blood pressure and reduce pain. This case report is about EVAR
27
procedure for type B aortic dissection with end-stage renal disease on hemodialysis patient, showing better
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outcome. Post-EVAR procedure, chest pain was relieved, blood pressure is controlled with two antihypertension
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drugs, and quality of life was improved. EVAR procedure closes the entry point of the false lumen, so blood
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entering through the true lumen and dissected area could be resolved.
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32 Conclusion. This case report shows successful outcome of EVAR procedure in aortic dissection with end-stage
33 renal disease. EVAR is minimally invasive, has fewer cardiovascular complications, and shows better outcomes,
34 these advantages made EVAR a promising treatment for type B aortic dissection.
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36 Keyword : aortic dissection, EVAR, hemodialysis, renal failure
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39 INTRODUCTION
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41 Aortic dissection is an emergency condition with various clinical presentations and death can occurs in hours.[1]
42 It is due to intimal tear that comes from high pressure into aortic wall that will make a new access to the blood
43 stream. It is known as a false lumen which contains blood from the teary entrance and can compress a true
44 lumen. This matter will cause bad condition such as internal bleeding, ischemia or infarct myocard, visceral
45 ischemia, and even death.[1–3] The correlation between aortic dissection and renal ischemia is likely correlate
46 to the existence of uncontrolled hypertension, which is the common risk factor of aortic dissection.[4]
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48 Aortic dissection on hemodialysis patient is a rare case. Ounissi et al revealed that of 7128 hemodialysis patients
49 from 1992 until 2007, the prevalence of aortic dissection is only 0.04%. In this study, the patients were
50 diagnosed with aortic dissection after several months undergoing hemodialysis and had cardiovascular risks
51 (such as hypertension, dyslipidemia, smoking, and vascular calcification). Death is likely to occur in
52 hemodialysis patients due to the late in recognition of this condition. Thus, early clinical identification of aortic
53 dissection is recommended, especially in patient with chest pain complaints [5]. Study of Takeda et al show
54 from 896 deaths in hemodialysis patients, 5.73% sudden deaths occurred among these patients due to aortic
55 dissection. This number is higher than aortic dissection insidence that reported in general population, which is
56 0.59% [6]. Understanding aortic dissection mechanism such as the pathogenesis, how to establish the diagnosis,
57 and to determine the suitable modalities of treatment are crucial. For the management of aortic dissection,
58 EVAR procedure is a new promising treatment with better outcomes and minimally invasive [5,6]. Through this
59 case report, we will present how EVAR procedure works in aortic dissection patient undergoing hemodialysis.
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22 Fig. 1 Chest X-Ray: Mediastinum enlargement and prominent aortic silhouette (orange line) (Left), aortic
23 dissecting line was showed in MSCT imaging (orange arrow) (Right)
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26 CASE REPORT
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28 Male, 38 y.o came to hospital complaining a prolonged left chest pain with sudden onset, when patient
29 undergoing hemodialysis, described as “tearing”, radiating from chest to the back and epigastric area since two
30 months ago. Patient also complained dispneu at rest due to volume overload, paroxysmal nocturnal dyspnea, and
31 orthopnoe. Patient had end stage renal disease and was undergoing hemodialysis routinely two until three times
32 a week. Physical examination showed blood pressure 210/110 mmHg with heart rate 90 times per minute,
33 reguler, equal, and respiratory rate 30 times per minute. It was also found a palpebra oedema and increased
34 Jugular Vein Pressure. Cardiovascular examination revealed cardiomegaly and diastolic murmur suggestive
35 aortic regurgitation. Lung examination showed rales in bilateral basal lung. Aortic abdominal diameter was
36 palpate widden, shifting dullness comfirmed, and bilateral pretibial oedema. Laboratory examination revealed
37 hemoglobin 9.1 g/dL, urea serum 203 mg/dL, creatinine serum 12.0 mg/dL, D-dimer >5000 ng/mL,
38 prothrombin time 32.6 seconds (control 11,1), and activated partial thromboplastin time 73.7 seconds (control
39 34,6). Chest X-ray appeared cardiothoracic ratio more than 70 percent with mediastinum enlargement,
40 widening of aortic silhouette and was prominent, and bilateral pleural effusion. Echocardiography showed
41 intimal flap from arcus aorta up to descendent aorta and accompanied by mild aortic regurgitation, mitral
42 regurgitation, and tricuspid regurgitation. CT angiography revealed aortic dissection in thoracooabdominalis as
43 long as 40 centimetres from proximal border in aortic arcus (after left subclavia artery) until aortic bifurcatio
44 thereby stanford type B aortic dissection was confirmed. Patient had been given intravenous theraphy perdipine,
45 starting from 0,1 µg/kgBB/minutes titration every 15 minutes with MAP goal 90-70 and morfin 10mg/hours.
46 After 20 days of admission, TEVAR/EVAR had done because prolonged chest pain with uncontrolled
47 hypertension with blood pressure 150/90 mmHg. Post-TEVAR, chest pain was resolved, blood pressure was
48 stable in value 130/90 mmHg with only two drug hypertension, and general status was normal.
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51 DISCUSSION
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53 Although insidence of aortic dissection in end-stage renal disease on hemodialysis patient is very rare, the
54 mortality rate is quite high [3]. This high mortality rate is due to the late of diagnosis and disease characteristic
55 which could be life threatening. Identification of risk factors such as uncontrolled hypertension, history of
56 previous heart disease, and spesific sign and symptoms related aortic dissection is needed for early diagnose so
57 the late of treatment could be prevented. Medical treatment aimed in lowering blood pressure and reducing pain
58 with close hemodynamic monitoring.
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3 False lumen
4 diameter
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7 Intimal flap
8 in aortic
9 arcus
10 True lumen
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12 diameter
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Intimal flap
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24 near left
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26 Intimal flap in aortic
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28 aortic arcus
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LV EF 60,1%, LVH Mitral regurgitation,
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43 consentric Tricuspid regurgitation
44 Fig. 2 Echocardiography showing intimal flap, true lumen, and false lumen (red circle and arrow)
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47 Chest pain during hemodialysis procedure is one of complication that could be happened, especially in patients
48 who have cardiovascular risks. When undergoing hemodialysis, heparin intravenous is given and resulting in the
49 aorta to become vulnerable. Beside that, renal failure adversely affects endothelial function, decreasing the
50 bioavailability of nitric oxide and vascular distensibility subsequently. Uncontrolled hypertension in patients
51 with renal failure produced high stress to the aortic wall and together with previous factor mentioned before
52 resulting in high chance to dissection [7,8]. Hence, this is likely to be the pathogenesis of aortic dissection in
53 hemodialysis patients.
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55 This case report shows recent EVAR procedure as treatment which has been done to treat type B aortic
56 dissection successfully and improved end-stage renal failure outcome. Post-EVAR procedure, chest pain was
57 resolved, blood pressure was controlled with two drug antihypertension, and quality of life had improved
58 periodically.
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 False lumen diameter True lumen diameter
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pre-TEVAR post-TEVAR
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True lumen diameter
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20 Fig. 3 Angiography pre-TEVAR (left) and post-TEVAR (right)
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22 The entry point of false lumen is closed by EVAR procedure so then all the blood enter through the true lumen
23 and in the end the dissected is resolved. EVAR procedure is a promising treatment with minimal complication
24 and has better outcome rather than open surgery [9,10]. Nienaber et all in INSTEAD trial reveale that TEVAR
25 procedure seems likely to improve the patient life expectancy up to 5 years and prevent clinical worsening of
26 aortic dissection type B [11,12]. Fattori et al describe that the mortality rate (33.9%) and complications (40%) of
27 open surgery is higher than the mortality rate (10.6%) and complications (20%) of TEVAR procedure [13].
28 Hogendorn et al also reveale that 30-day mortality rate in open surgery is 7.3% higher rather than TEVAR
29 procedure for management of aortic dissection type B [14]. Long term monitoring is needed after TEVAR
30 procedure. It is due to some complications such as graft stent collapse, graft stent migration, graft stent torsion,
31 trombus on stent, and late rupture that must be taken to concern of. Post-TEVAR procedure, clinical monitoring
32 accompanied by imaging are the best option for patient follow-up [15].
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36 CONCLUSION
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38 Aortic dissection Standford type B is a rare case among hemodialysis patient. Since the mortality of aortic
39 dissection is complicated by renal failure is high, early diagnosis and treatment is crucial with high index
40 suspicion in patient who come with chest pain. This case report shows successful outcome of EVAR procedure
41 in aortic dissection with end-stage renal disease. Decreasing cardiovascular complications, minimally invasive,
42 and give better outcomes are of that the important points of EVAR procedure making it an excellent modality
43 treatment for aortic dissection Standford type B.
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59 Fig. 4 Chest X-Ray post-TEVAR (left) and MRI post-TEVAR (right)
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 Compliance with Ethical Standards
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2 All procedures performed in studies involving human participants were in accordance with the ethical standards
3 of the institutional and/or national research committee at which the studies were conducted and with the 1964
4 Helsinki declaration and its later amendments or comparable ethical standards.
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6 Conflict of interest
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8 All the authors have declared no competing interest.
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10 Informed consent
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12 Informed consent was obtained from all individual participants included in the study
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15 REFERENCES
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22 Elsevier Inc.; 2015:1288-1292.
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38 9. Alsac JM, Girault A, El Batti S, Abou Rjelli M, Alomran F, Achouh P, Julia P FJ. Experience of the
39 Zenith dissection endovascular system in emergency setting of malperfusion in acute type B dissection.
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41 10. Wilkinson DA, Patel HJ, Williams DM, Dasika NL DG. Early open and endovascular thoracic aortic
42 repair for complicated type B aortic dissection. Ann Thorac Surg. 2013;96:23-30.
43 11. Nienaber CA et al. Randomized comparison of strategies for type B aortic dissection:the Investigation
44 of Stent grafts in Aortic Dissection (INSTEAD) trial. Circulation. 2009;120:2519-2528.
45 12. Nienaber CA KS et al. Endovascular repair of type B aortic dissection: long term results of the
46 randomized investigation of stent grafts in aortic dissections trial. Circulation. 2013;6:407-416.
47 13. Fattori R et al. Complicated acute type B dissection: is surgery still the best options? A report from the
48 International Registry of Acute Aortic Dissection. J Am Coll Cardiol Interv. 2008;1(4):395-402.
49 doi:10.1016/j.jcin.2008.04.009.
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14. Hogendoorn W, Hunink Mg, Schlosser FJ, Moll FL, Sumpio BE MB. Endovascular vs open repair of
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complicated acute type B aortic dissections. J Endovasc Ther. 2014;21:503-514.
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15. Swee W DM. Endovascular management of thoracic dissections. Circulation. 2008;117:1460-1473.
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