Aortic Dissection with Peripheral

Vascular Complications

Ri 陳宥伶
Patient History
 黃X聰
 5302643
 39 y/o man
 Denied systemic disease including

HTN, dyslipidemia
 No frequent arthragia or headache
 Medical History

 2008/4/27: While riding motorcycle

 Sudden onset severe chest pain
 Hit the electric pole by himself
 He was sent to 二林基督教 hospital
 Brain CT: left SDH, SAH, ICH

(Cont.)
 Medical History (Cont.)

 Referred to 童綜合 hospital

 CT revealed dissection of descending aorta,
DeBakey type B to infrarenal level with
hemopneumothorax
 Patent SMA and celiac trunk
 Hypoperfused right kidney and lower pole
of left kidney
 Oliguria(+): ARF + Rhabdomyolysis
 4/30: Transferred to NTUH due to family
requested
(Cont.)
 Abdominal CT on 4/30

 Aortic dissection with intimal flap

noted from distal aortic arch to
abdominal aorta bifurcation.
 Aorta is not dilated.
 R’t kidney hypoperfusion. Occlusion of
right renal artery by the intimal flap is
considered.
 No obvious occlusion of iliac artery
R’t
L’t
 Medical History (Cont.)

 Pale and cold left foot :↓pulsation

 Suspect ischemia
 4/30: Femoro-femoral bypass
 Consciousness fluctuation
(Brain CT on 4/30: Bil. SDH + ICH with brain
swelling and mild midline shift but the NS
suggested the injury range would not
affect conscious level)
 No ischemia of upper limbs, BP and pulse
were intact over bilateral arms
 Despite persistent high BP (Cont.)
 Medical History (Cont.)

4/30~5/8:
 WBC↑, bowel sound↓, Amy/Lip/LFT↑
 Suspect ischemic bowel
 Abdominal CT: proximal SMA occlusion +
suspect splenic and L’t kidney infarct
 5/9: SMA-external iliac artery bypass
 No other vascular insults thereafter

(Cont.)
 Medical History (Cont.)
 Follow up CT on 5/13:
 Aortic dissection from posterior aortic arch down
to the right common iliac artery. Both true lumen
and false lumen are patent. Involving SMA &
bilateral renal arteries
 No progression of dissection
 Current management to DAA:
Keep SBP< 160 mmHg (perdipine cIF)
Add β blocker
On regular H/D
→ BP is still high: SBP = 160~180 sometimes
 Consciousness still not clear, s/p VATS for right
empyema, fever(+), treated as infection
 Discussion I

Branch Vessel Involvement of DAA

 Deadly Triad of DAA

 Hypotension/Shock
 Absence of chest/back pain initially
 Branch vessel involvement

(Nienaber et al. 2003)

 Branch Vessels Involved
 Branch of aorta:
 Type A : Coronary a. → AMI
Subclavian a. Ischemic upper
Brachiocephalic a. limbs or stroke
Carotid a. → Stroke
Spinal a. → Paraplegia
 Type B : Renal a. → Renal failure
SMA → Ischemic bowel syndrome
Celiac trunk → splenic infarct
Iliac a. → Ischemic legs
Spinal a. → Paraplegia
 Incidence
 Fann et al. 1990
272 pts (73% type A, 27% type B), 31% with peripheral vascular
complications
 Visceral malperfusion 5%
 Impaired renal perfusion 8%
 Loss of peripheral pulse 24%
Incidence
 Incidence
 Estrera et al. 2007
159 pts (Acute type B)
 GI ischemia 5.6%
 Acute renal faiure 20%
 Lower extremity ischemia 4.4%
 Types of Obstruction
Williams et al. 1997
 Static
 Dynamic
 Static + Dynamic
 Diagnosis

 Aortography
 Angiography: filling defect
 Intravascular ultrasound: curtainlike
occlusion of vessels
 Manometry: arterial pressure deficit
 In Our Patient

 Only CT evidence of hypoperfusion

 Renal a. (4/27): kidney already infarct
 SMA (5/8): total proximal occlusion
 Iliac a. (4/30): No definite occlusion
was seen but there was intimal flap
Discussion II

Treatment
 Operative mortality risk (Fann et al. 1990)

 The operative mortality rate for all patients was 25% (68 of 272 patients).
 High operative mortality:
Paraplegia 44% ± 17%
Impaired renal perfusion 50% ± 11%
Visceral malperfusion 43% ± 14%
 Lower mortality rates:
Stroke 14% ± 14%
Loss of peripheral pulse 27% ± 6%
 Management of peripheral
vascular complications (Hughes et al. 1995)

 Visceral & bowel ischemia (delayed occurrence)

 Renal artery complications (2hr)
 Obstructive extremity complications (easier)

 The majority resolved after repair of the aortic

dissection

 Peripheral vascular procedure is required only

infrequently
 Treatment of Aortic Dissection

 Medical (Estrera et al. 2007)

BP control (<140) and pain control
Acceptable outcomes, especially in
uncomplicated cases

Indication of vascular surgical intervention:

1. Rupture
2. Aortic expansion (>5cm)
3. Retrograde dissection to ascending aorta
4. Visceral and peripheral malperfusion
5. Intractable pain
 Treatment of Aortic Dissection

 Surgical (Fann et al. 1990)

1. Earlier diagnosis and operation for patients with
compromised renal and/or visceral perfusion to
minimize lethal complications
2. Repair aorta first
3. Outcome of repair aorta: less favorable in
patients with paraplegia, renal failure and
ischemic bowel syndrome

 Endovascular graft (Eggebrecht et al. 2005)

Lauterbach et al 2001

?
 In Our Patient

 DAA itself: medical treatment

Probably due to risk elevation due to
renal failure and stabilized dissection
 Obstructed branch vessels:

*Renal a.: out of golden time: on H/D

*SMA: bypass surgery
*Iliac artery: F-F bypass
 References

 Eggebrecht et al. Eur Heart J 2006;27:489 –98.

 Estrera et al. Ann Thorac Surg 2007;83:S842–5.

 Fann et al. Circulation 1995;92: II113–21.

 Hughes et al. American Journal of Surgery 1995; 170(2):209-

12.

 Nienaber et al. Circulation 2003; 108[Suppl II]: 312-317

 Lauterbach et al. J Vascular Surgery 2001; 33: 1185-1192

 Shiiya et al. Gen Thorac Cardiovasc Surg 2007; 55: 85-90

 Williams et al. Radiology 1997; 203: 37-44

 The End

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