B Quiroga

CA Nienaber

CJ Parsa

DA Wilkinson

JM Alsac

PJ Mossop

R Fattori

T Akizawa

T Kitamura

W Hogendoorn

W Swee

Yuko Miyazaki

Tadashi Furuyama

Yutaka Matsubara

Keiji Yoshiya

Ryosuke Yoshiga

Kentaro Inoue

Daisuke Matsuda

Yukihiko Aoyagi

Masaaki Kato

Takuya Matsumoto

Yoshihiko Maehara

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CASE REPORT Open AccessThoracic endovascular aortic repair forcomplicated chronic type B aorticdissection in a patient on hemodialysiswith recurrent ischemic colitisYuko Miyazaki1, Tadashi Furuyama1, Yutaka Matsubara1, Keiji Yoshiya1, Ryosuke Yoshiga1, Kentaro Inoue1,Daisuke Matsuda1, Yukihiko Aoyagi1, Masaaki Kato2, Takuya Matsumoto1* and Yoshihiko Maehara1AbstractWe present a successful case of thoracic endovascular aortic repair (TEVAR) for chronic Stanford type B aorticdissection (B-AD) with recurrent ischemic colitis. The patient was a 56-year-old woman with abdominal pain as themain complaint who had two operations previously: the total arch replacement 8 years ago and the Bentall 7 yearsago for acute Stanford type A aortic dissection. Her abdominal pain worsened as her blood pressure became lowduring her hemodialysis treatment. An enhanced computed tomography scan was performed on the patient andshowed chronic B-AD that occurred from the distal anastomotic part of the total arch graft to the bilateral commoniliac arteries. The celiac artery and superior mesenteric artery (SMA) arose from the true lumen, and these werecompressed by the expanded false lumen. Her complicated chronic B-AD was treated with the Zenith DissectionEndovascular System, and its procedure was performed as her proximal entry tear was covered by a proximaltapered Zenith TX2 stent graft, supplemented by a noncovered aortic stent extending across both renal arteries,the SMA, and the celiac artery. Seven days after this operation, enhanced computed tomography showed that thepatient’s true lumen was expanded and her blood flow to the true lumen and SMA was improved. On the otherhand, her false lumen tended to be thrombosed. Consequently, she was discharged 10 days after the operationwithout any postoperative complications as she had no abdominal complaints even though she underwenthemodialysis three times per week after the operation. We believe that TEVAR supplemented by a noncoveredaortic stent is an effective treatment, even for highly chronic B-AD in dialysis patients.Keywords: Thoracic endovascular aortic repair, Chronic type B aortic dissection, Ischemic colitis, Malperfusion,Surgical interventionBackgroundEndovascular techniques and devices have recentlybeen developed for the management of aortic dissection[1–3]. Recently, the INSTEAD-XL study showed thatthoracic endovascular aortic repair (TEVAR) can improvethe survival rate of up to 5 years for aorta-specific casesand delayed the disease progression of stable Stanford typeB aortic dissection (B-AD) with suitable anatomy [4, 5]even though B-AD can be complicated by various symp-toms such as uncontrollable hypertension, aortic rupture,and end-organ ischemia [4, 5]. However, the effectivenessof TEVAR for such complicated chronic B-AD of patientsis still an ongoing debate. Additionally, patients with end-stage renal failure (ESRF) on hemodialysis have many ath-erosclerotic comorbidities including ischemic colitis [6].We present here a rare case of chronic B-AD in a dialy-sis patient. The patient had been followed up for 8 yearsand developed ischemic colitis repeatedly along withhypotension due to hemodialysis. We performed TEVARwith a noncovered aortic stent for this complicatedchronic B-AD.* Correspondence: takum@surg2.med.kyushu-u.ac.jp1Department of Surgery and Science, Graduate School of Medical Sciences,Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582 Fukuoka,JapanFull list of author information is available at the end of the article© 2016 Miyazaki et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made.Miyazaki et al. Surgical Case Reports  (2016) 2:38 DOI 10.1186/s40792-016-0165-2Case presentationThe patient was a 56-year-old woman with recurrentabdominal pain as the main complaint and who hadbeen on maintenance hemodialysis of ESRF for 26 years.She had the operations of total arch replacement 8 yearsago and a Bentall 7 years ago for acute Stanford type Aaortic dissection. Although dissections still remainedon the descending thoracic and abdominal aorta fromthe previous two operations, the diameter of the aortaremained stable without its enlargement. Therefore, sheunderwent conservative treatments.Her initial abdominal pain with ischemic colitis oc-curred 1 year ago, and colonoscopy was performed. Bythe diagnosis of the colonoscopy, we found a whitecoating in the vicinity of the Bauhin valve and localizeddistorted ulcers in the ascending colon. However, mu-cosal necrosis was not found (Fig. 1). Since her symp-toms were slight and temporary, she remained onconservative treatments at that time. Her abdominalpain became worse; melena occurred often during thecourse of her conservative treatments, and these symp-toms occurred when blood pressure became low underhemodialysis. Then, she was referred to our hospital forfurther evaluation of her recurrent ischemic colitis.Computed tomography (CT) scans showed chronic B-AD, which extended from the distal anastomotic part ofthe total arch graft to both common iliac arteries. Thedistal re-entry size was 26 mm. The expanded falselumen compressed the true lumen of most of the aorta,including the origin of the superior mesenteric artery(SMA) (Fig. 2).Based on these clinical findings, we considered thatthis recurrent ischemic colitis was a result of diminishedblood flow to the SMA due to the compressed truelumen combined with hypotension due to hemodialysis.We then determined that therapeutic enlargement of thetrue lumen would improve blood flow to the SMA andreduce the risk of ischemic colitis. For treatment, we de-cided to perform TEVAR because open surgical repaircan be risky for the patient considering the history ofprevious Bentall operation and comorbid ESRF. Be-cause the patient’s quality of life was adversely affectedby recurrent ischemic colitis, she agreed to undergo theprocedure we suggested, and informed consent was ob-tained. The operation was performed under generalanesthesia. An incision was made in the right groin toexpose the right femoral artery. A 6Fr sheath intro-ducer was inserted percutaneously from the left com-mon femoral artery for aortography. A 8Fr sheathintroducer was inserted from the right exposed com-mon femoral artery, and we delivered a guidewire andcatheter with contrast radiography to pass into thecompressed true lumen. The proximal entry tear in thepatient was covered by a Zenith TX2 stent graft (diam-eter, 32–28 mm; mean length, 200 mm; Cook Medical,Bloomington, IN), supplemented by a noncovered aor-tic stent (TXD; diameter, 36 mm; length, 164 mm;Cook Medical) around both renal arteries, the SMA,and the celiac artery (CA). The TX2 was deployed justdistal to the left subclavian branch to seal the entry tear(Fig. 3a). The noncovered aortic stent (TXD) was de-ployed from above the CA to under both renal arteriesto expand the true lumen and to improve blood flow ofthe CA and SMA (Fig. 3b). The operation time was 2 hand 33 min, and blood loss was 150 cc. The patient tol-erated these procedures well and was transferred to thepostoperative care unit in a hemodynamically stablecondition. Her bowel condition improved just after theoperation.Seven days after the operation, CT showed improvedblood flow in the true lumen, CA, and SMA, and thefalse lumen tended to be thrombosed (Fig. 4). She wasdischarged 10 days after the operation without any post-operative complications. She then underwent hemodialysisthree times per week after the operation, but her abdom-inal pain following hypotension due to hemodialysis hadcompletely disappeared. She remained well for 6 monthsafter the operation.Fig. 1 a A white coating could be seen in the vicinity of the Bauhin valve. b Localized distorted ulcers could be seen in the ascending colon. Mucosalnecrosis was not foundMiyazaki et al. Surgical Case Reports  (2016) 2:38 Page 2 of 5DiscussionWe experienced successful TEVAR for complicated chronicB-AD. The patient had ischemic complications 8 yearsafter the conservative treatments for chronic B-AD.This clinical course is rare because it took a long periodof 8 years for ischemic colitis to appear after the occur-rence of B-AD [7]. Furthermore, the occurrence of is-chemic colitis on this patient was not easily recognizedsolely through the history of hemodialysis-dependentESRF. Ischemic colitis is a well-known complication ofESRF [8], and abdominal pain after hemodialysis canthen often occur because of hypovolemia. Preoperatively,in our patient, we observed that ischemic colitis underhemodialysis was coincidentally worsened by chronic B-AD. Interestingly, however, the abdominal ischemic symp-toms disappeared completely after TEVAR. This clinicalcourse suggested that the ischemic colitis was mainlycaused by chronic B-AD and the relative hypovolemia fol-lowing hemodialysis which had worsened the ischemiccondition. Therefore, physicians should carefully evaluateFig. 2 The true lumen (T) and superior mesenteric artery (SMA) were compressed by the expanded false lumen (F). a Sagittal slice, b axial slice atthe level of bronchial bifurcation, and c axial slice at the level of the SMA. T true lumen, F false lumenFig. 3 a The TX2 was deployed just distal to the left subclavian branch to seal the entry of the false lumen. b The TXD was deployed at the SMAto expand the true lumen and improve blood flow of the SMAMiyazaki et al. Surgical Case Reports  (2016) 2:38 Page 3 of 5the effect of stable chronic B-AD on ischemic colitisconsidering ischemic colitis may take a long period oftime to appear after chronic B-AD and diagnosis ofischemic colitis is difficult.With regard to treatment of B-AD, TEVAR is less in-vasive and an effective treatment compared with opensurgery [9]. Fattori et al. demonstrated that operativemortality and complications were 33.9 and 40 % in opensurgery compared with 10.6 and 20 % in TEVAR, re-spectively [10]. Hogendoorn et al. also reported that the30-day mortality rate was 17.5 % in open surgery and10.2 % in TEVAR [11]. In addition, TEVAR has betteraorta-specific survival and delayed disease progressionthan conservative treatment [3]. Currently, TEVAR is agood treatment option for B-AD and is expected to beeffective, even for complicated cases.In the present case, the purpose of surgical treatmentwas to expand the true lumen and improve blood flowinto the SMA. No aortic dilatation or rapid expansionwas found in our case. We considered that our patienthad many risks for surgical treatment because of hercomorbidities. Therefore, we performed TEVAR withthe TX2 in the proximal site to seal the entry tear andthe TXD was deployed at the SMA to expand the truelumen and improve blood flow in the SMA. We did notexpect that TEVAR above the CA could demonstrate theproper radial force to expand the true lumen below theCA because the dissection had occurred 8 years ago andthe vessel wall could be highly sclerotic. In our case,organ ischemia was severe enough that an improvementof SMA blood flow was required. With regard to the dis-tal site, the TXD which was composed of a noncoveredaortic stent contributed to maintaining the opening ofthe origin of the SMA. At the same time, use of a baremetal stent allowed the remaining flow to the false lumen.In general, such endoleak is a risk for progression of aorticdilatation. TEVAR sometimes causes retrograde aorticdissection, which often requires immediate open surgicalrepair [12]. Therefore, covering the true lumen and ex-tending into the thoracoabdominal aorta with a noncov-ered aortic stent to diminish retrograde endoleak could beimportant. In addition, flow to the artery of Adamkiewiczcould contribute to prevent acute vertebral ischemia.In our patient, TEVAR supplemented with a noncov-ered aortic stent was successful as the initial procedure.However, the long-term outcome is also important. Thepurpose of TEVAR for chronic B-AD includes not onlyimproving prognosis but also preventing future surgicalintervention of aortic dilatation [13]. Physicians need tobe aware of other complications of TEVAR, such asstent-graft collapse, stent-graft migration, stent-graft tor-sion, aortoesophageal fistula, mobile thrombus withinthe stent-graft lumen, aneurysm formation, and late rup-ture. These complications warrant the importance ofclose and lifelong imaging follow-up of these patients[12]. Therefore, after TEVAR for B-AD, patients shouldbe carefully followed up to identify any complications.ConclusionsWe present a rare case of chronic B-AD with unique is-chemic colitis, which worsened following hypotensiondue to hemodialysis. Our treatment with TEVAR supple-mented with a noncovered aortic stent was successful.We believe that TEVAR is a good treatment option, evenFig. 4 Blood flow of the true lumen and SMA was improved. The false lumen remained but tended to be thrombosed. a Sagittal slice, b axialslice at the level of bronchial bifurcation, and c axial slice at the level of the SMA. T true lumen, F false lumenMiyazaki et al. Surgical Case Reports  (2016) 2:38 Page 4 of 5for complicated chronic B-AD, including especially chroniccases or cases causing organ ischemia. Further studies arerequired to validate the optimal indication and effective-ness of TEVAR for complicated chronic B-AD.ConsentWritten informed consent was obtained from the patientfor publication of this Case Report and accompanyingimages. A copy of the written consent is available forreview by the Editor-in-Chief of this journal.AbbreviationsB-AD: Stanford type B aortic dissection; SMA: superior mesenteric artery;TEVAR: thoracic endovascular aortic repair.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsYukM, TF, YutM, KI, and TM wrote the manuscript. TF and TM treated thepatient and performed the operation. YutM, KY, RY, KI, DM, and YAperformed the follow-up and obtained the informed consent for thepatient. TM, MK, and YoM organized the treatment for the patient andwrote the manuscript. All authors read and approved the final manuscript.Author details1Department of Surgery and Science, Graduate School of Medical Sciences,Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582 Fukuoka,Japan. 2Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka,Japan.Received: 14 December 2015 Accepted: 11 April 2016References1. Yoshiga R, Morisaki K, Matsubara Y, Yoshiya K, Inoue K, Matsuda D, et al.Emergency thoracic aortic stent-grafting for acute complicated type B aorticdissection after a previous abdominal endovascular aneurysm repair. SurgCase Reports 2015 (in press)2. Parsa CJ, Schroder JN, Daneshmand MA, McCann RL, Hughes GC. Midtermresults for endovascular repair of complicated acute and chronic type Baortic dissection. Ann Thorac Surg. 2010;89:97–102. discussion 102-4.3. Alsac JM, Girault A, El Batti S, Abou Rjeili M, Alomran F, Achouh P, Julia P,Fabiani JN. Experience of the Zenith Dissection Endovascular System in theemergency setting of malperfusion in acute type B dissections. J Vasc Surg.2014;59:645–50.4. Nienaber CA, Kische S, Rousseau H, Eggebrecht H, Rehders TC, Kundt G,Glass A, Scheinert D, Czerny M, Kleinfeldt T, Zipfel B, Labrousse L, Fattori R,Ince H. Endovascular repair of type B aortic dissection: long-term results ofthe randomized investigation of stent grafts in aortic dissection trial.Circulation. 2013;6:407–16.5. Nienaber CA, Rousseau H, Eggebrecht H, Kische S, Fattori R, Rehders TC,Kundt G, Scheinert D, Czerny M, Kleinfeldt T, Zipfel B, Labrousse L, Ince H,INSTEAD Trial. Randomized comparison of strategies for type B aorticdissection: the INvestigation of STEnt Grafts in Aortic Dissection(INSTEAD) trial. Circulation. 2009;120:2519–28.6. Akizawa T, Kameoka C, Kaneko Y, Kawasaki S, Bixalomer Study Group. Long-term treatment of hyperphosphatemia with bixalomer in Japanesehemodialysis patients. Ther Apher Dial. 2013;17:612–9.7. Mossop PJ, McLachlan CS, Amukotuwa SA, Nixon IK. Staged endovasculartreatment for complicated type B aortic dissection. Nat Clin PractCardiovasc Med. 2005;2:316–21.8. Quiroga B. Increase of ischaemic colitis incidence in haemodialysis.Nefrologia. 2014;34:526–7.9. Wilkinson DA, Patel HJ, Williams DM, Dasika NL, Deeb GM. Early open andendovascular thoracic aortic repair for complicated type B aortic dissection.Ann Thorac Surg. 2013;96:23–30.10. Fattori R. Complicated acute type B dissection: is surgery still the bestoption? A report from the International Registry of Acute Aortic Dissection. IAm Coll Cardiol Interv. 2008;1:395–402.11. Hogendoorn W, Hunink MG, Schlösser FJ, Moll FL, Sumpio BE, Muhs BE.Endovascular vs. open repair of complicated acute type b aortic dissections.J Endovasc Ther. 2014;21:503–14.12. Swee W, Dake MD. Endovascular management of thoracic dissections.Circulation. 2008;117:1460–73.13. Kitamura T, Torii S, Oka N, Horai T, Nakashima K, Itatani K, Koyama S, Hari Y,Araki H, Sato H, Miyaji K. Key success factors for thoracic endovascular aorticrepair for non-acute Stanford type B aortic dissection. Eur J CardiothoracSurg. 2014;46:432–7.Submit your manuscript to a journal and beneﬁ t from:7 Convenient online submission7 Rigorous peer review7 Immediate publication on acceptance7 Open access: articles freely available online7 High visibility within the ﬁ eld7 Retaining the copyright to your article    Submit your next manuscript at 7 springeropen.comMiyazaki et al. Surgical Case Reports  (2016) 2:38 Page 5 of 5

Surgical Case Reports

Thoracic endovascular aortic repair for complicated chronic type B aortic dissection in a patient on hemodialysis with recurrent ischemic colitis

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Thoracic endovascular aortic repair for complicated chronic type B aortic dissection in a patient on hemodialysis with recurrent ischemic colitis

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