Acute aortic dissection bears all the stigmata of a true clinical emergency. The natural history of this acute aortic syndrome warrants prompt surgical intervention, with only a few absolute contraindications to this line of treatment. We present a 74-year-old man with documented metastatic prostate cancer who underwent emergent surgery for acute Stanford A aortic dissection. Having acknowledged the relatively favorable evolution of our patient’s malignant disease, we were not deterred by its presence from pursuing surgical treatment of his aortic dissection

Franjo Širić

Hrvoje Gašparović

Ivan Burcar

Ivan Jelić

Jakov Vojković

Ranka Stern-Padovan

English

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Coll. Antropol. 34 (2010) 3: 1109–1111Case reportSurgical Treatment of Aortic Dissection in aPatient with Metastatic Prostate CancerHrvoje Ga{parovi}, Franjo [iri}, Jakov Vojkovi}, Ranka Stern-Padovan, Ivan Burcar and Ivan Jeli}Departments of Cardiac Surgery and Radiology, Zagreb University Hospital Center, Zagreb, CroatiaA B S T R A C TAcute aortic dissection bears all the stigmata of a true clinical emergency. The natural history of this acute aortic syn-drome warrants prompt surgical intervention, with only a few absolute contraindications to this line of treatment. Wepresent a 74-year-old man with documented metastatic prostate cancer who underwent emergent surgery for acute Stan-ford A aortic dissection. Having acknowledged the relatively favorable evolution of our patient’s malignant disease, wewere not deterred by its presence from pursuing surgical treatment of his aortic dissection.Key words: aortic dissection, surgery, metastatic cancerIntroductionProstate cancer is the most common cancer in men inEurope and North America, with its worldwide incidenceprogressively increasing1. Risk factors for its develop-ment include, among others, a genetic susceptibility, age,ethnicity and certain dietary factors1. The poor prognosisof untreated Stanford A dissections merits immediatesurgical attention2,3. While there are many factors pre-cipitating the mechanical disruption of the aortic intima,disseminated malignant disease has not been identifiedas a predisposing condition. The paucity of data in the lit-erature addressing the issue of management of aortic dis-sections in patients with disseminated malignant dis-ease, however, leaves the role of surgery in this patientpopulation unclear.Case ReportWe report on a 74 year old man with a history of dis-seminated prostate cancer who presented to the emer-gency department with acute chest pain radiating to hisback. A diagnostic work up, which included a trans-thoracic echocardiogram and contrast enhanced CT aor-tography, revealed a Stanford A aortic dissection. His ini-tial diagnosis of prostate cancer antedated this event byfive years, and was treated with maximal androgen blo-ckade using goserelin and flutamide4. He was known tohave malignant dissemination to his lymph nodes, whichwas corroborated once again by the presently performedCT scan (Figure 1). His most recent level of prostate spe-cific antigen (PSA) was 5 ng/mL. Of note, the patient alsohad a history of a transitory neurologic deficit as well asfemoral artery thrombosis, which were both believed tobe parts of a paraneoplastic syndrome.Given the ominous prognosis of surgically untreatedStanford A aortic dissection we believed that the benefitof surgery outweighed its substantial risk. The CT an-giogram clearly demonstrated an intimal flap within theascending aorta consistent with a type A aortic dissection(Figure 2). Lower level CT scans established the progres-sion of the dissection into the abdominal aorta, and alsoimaged the neoplastic lymph node involvement.Mild insufficiency of his aortic valve was documentedby both transthoracic and intraoperative transesopha-geal echocardiography. No evidence of pericardial tampo-nade or end-organ malperfusion was found. Cardiopul-monary bypass was established via cannulation of the1109Received for publication June 1, 2008right axillary artery and the right atrium. The intra-operative findings confirmed the diagnosis of aortic dis-section, with the intimal tear found on the convex aspectof the ascending aorta. The operative strategy entailedreplacement of the diseased segment of the supraco-ronary ascending aorta with a Dacron vascular prosthe-sis using moderately hypothermic extracorporeal circula-tion (28°C). The dissected layers of the aorta werereapproximated using circumferential teflon felt stripscomplemented with gelatin-resorcinol-formalin glue.The aortic reconstruction was further complementedwith aortic valve resuspension within the Dacron graft toensure lasting aortic valve competency. We deviated fromour standard operative technique for Stanford A aorticdissections, which involves creating an open distal anas-tomosis under circulatory arrest. The distal anastomosiswas, in this case, constructed with the distal ascendingaorta cross-clamped just below the take off of the inno-minate artery. The early postoperative course was re-markable only for pneumonia, which resolved with ap-propriate antibiotic management. The patient was dis-charged home 14 days after surgery. He was seen at fol-low up one month later by which time he had resumedmost of his daily activities. Six months later, however, hepresented with new onset paraparesis and was found tohave multiple osseous metastases to his ribs and verte-brae. The PSA level at that time increased to 633 ng/ml.His prostate cancer was thought to have become hor-mone-refractory, necessitating the institution of secondline therapy with estramustine. He responded favorablyto palliative radiation, which enabled him to become am-bulatory with crutches. Fourteen months after his sur-gery he remains alive, without any new developments inhis clinical status.DiscussionOur report brings into focus the management strat-egy of a complex patient suffering from two ultimatelyfatal conditions: the more insidious prostate cancer andthe very acute aortic dissection. The former did not, inour opinion, contraindicate the appropriate managementof the latter. There is no data in the literature that reli-ably suggest that the use of cardiopulmonary bypassmight in any way enhance the dissemination of the ma-lignant process. A wide spectrum of coagulation distur-bances have been known to occur in metastatic prostatecancer, and these include disseminated intravascular co-agulation, thrombocytopenic thrombotic purpura, throm-bosis, Trousseau’s syndrome and acquired factor VIII in-hibitor development5.While the use of deep hypothermic circulatory arrestis considered the standard of care for the construction ofthe distal aortic anastomosis in patients with aortic dis-sections, it is associated with platelet dysfunction, as wellas multiple derangements in the coagulation cascade. Wewere, therefore, inclined to avoid profound hypothermiain the present case and all of its associated sequelae onthe already disturbed coagulation mechanism. The un-certain interrelationship between disseminated malig-nant disease, circulatory arrest and the associated coa-gulopathy in a patient requiring major aortic surgeryprompted us to avoid deep hypothermia at the expense ofaortic cross-clamping. The described management strat-egy of our patient, which adheres to the principal surgi-cal dogma in the treatment of this acute aortic syndrome,granted our patient survival beyond that of the expectednatural history of this condition.R E F E R E N C E S1. GRONBERG H, Lancet, 361 (2003) 859. — 2. GREEN GR, KRONIL, Aortic Dissection. In: COHN LH, EDMUNDS LH (Eds) Cardiac Sur-gery in the Adult (McGraw-Hill, New York, 2003). — 3. PRETRE R, VONSEGESSER LK, Lancet, 349 (1997) 1461. — 4. CHODAK GW, Rev Urol,46 (2000) Suppl 18. — 5. DE LA FOUCHARDIERE C, FLECHON A,DROZ JP, Neth J Med, 61 (2003) 347.H. Ga{parovi} et al.: Aortic Dissection Surgery and Metastatic Cancer, Coll. Antropol. 34 (2010) 3: 1109–11111110Fig. 1. Coronal CT image of a lymph node package (arrows) in-dicative of malignant dissemination of the previously documen-ted known prostate cancer.Fig. 2. Axial CT angiography showing an intimal flap consistentwith aortic dissection in the ascending (A) and descending aorta(B).F. [iri}Department of Cardiac Surgery, Zagreb University Hospital Center, Ki{pati}eva 12, 10 000 Zagreb, Croatiae-mail: franjosiric1@yahoo.comLIJE^ENJE AKUTNE DISEKCIJE AORTE U BOLESNIKA S METASTATSKIM KARCINOMOMPROSTATES A @ E T A KAkutna disekcija aorte eklatantni je primjer hitnoga kirur{kog stanja. Smrtonosan tijek bolesti zahtijeva hitnu ki-rur{ku intervenciju uz rijetke apsolutne kontraindikacije za hitni kirur{ki zahvat. Ovdje opisujemo slu~aj 74 godinestaroga mu{karca s dijagnosticiranim metastatskim karcinomom prostate koji je podvrgnut kirur{kom lije~enju akutnedisekcije aorte tipa Stanford A. Usprkos postojanju diseminiranog karcinoma prostate odlu~ili smo se za kirur{ki tret-man akutne disekcije aorte uva`avaju}i tijek i prognozu njegove osnovne maligne bolesti.H. Ga{parovi} et al.: Aortic Dissection Surgery and Metastatic Cancer, Coll. Antropol. 34 (2010) 3: 1109–11111111

Surgical Treatment of Aortic Dissection in a Patient with Metastatic Prostate Cancer

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Surgical Treatment of Aortic Dissection in a Patient with Metastatic Prostate Cancer

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