Intraoperative iatrogenic type A aortic dissection is a rare but known complication of cardiac surgery, with an incidence of 0.06% to 0.23%. Results are frequently catastrophic. The endovascular approach has made advances as an alternative treatment for aortic disease. However, the apical approach for transcatheter thoracic endovascular aortic repair is not well known. We present a 5-year follow-up of a case of iatrogenic type A aortic dissection after minimally invasive mitral valve repair successfully resolved by medical stabilization and subsequent transapical thoracic endovascular aortic repair

Herrera, Raul

Katzen, Barry

Kim, Sangmin

Moreno, Niberto

English

Scholarly Commons@Baptist Health South Florida

Baptist Health South FloridaScholarly Commons @ Baptist Health South FloridaAll Publications2018Transapical endovascular repair of iatrogenic type Aaortic dissectionSangmin KimMiami Cardiac & Vascular Institute, SangminK@baptisthealth.netRaul HerreraMiami Cardiac & Vascular Institute, raulh@baptisthealth.netNiberto MorenoMiami Cardiac & Vascular Institute, nibertom@baptisthealth.netBarry KatzenBaptist Hospital of Miami; Miami Cardiac & Vascular Institute, barryk@baptisthealth.netFollow this and additional works at: https://scholarlycommons.baptisthealth.net/se-all-publicationsThis Article -- Open Access is brought to you for free and open access by Scholarly Commons @ Baptist Health South Florida. It has been accepted forinclusion in All Publications by an authorized administrator of Scholarly Commons @ Baptist Health South Florida. For more information, pleasecontact Carrief@baptisthealth.net.CitationJ Vasc Surg Cases Innov Tech (2018) 4(3):257-261Transapical endovascular repair of iatrogenic type A aorticdissectionSangmin Kim, MD,a,b,c Cristobal Ducaud, BS,b Raul E. Herrera, MD,a Nibert Moreno, MD,dJuan C. Zevallos, MD,b and Barry T. Katzen, MD,a Miami, Fla; and Cheongju, Republic of KoreaABSTRACTIntraoperative iatrogenic type A aortic dissection is a rare but known complication of cardiac surgery, with an incidence of0.06% to 0.23%. Results are frequently catastrophic. The endovascular approach has made advances as an alternativetreatment for aortic disease. However, the apical approach for transcatheter thoracic endovascular aortic repair is not wellknown. We present a 5-year follow-up of a case of iatrogenic type A aortic dissection after minimally invasive mitralvalve repair successfully resolved by medical stabilization and subsequent transapical thoracic endovascular aorticrepair. (J Vasc Surg Cases and Innovative Techniques 2018;4:257-61.)Keywords: Aortic dissection; Endograft; TransapicalIntraoperative iatrogenic aortic dissection is a rare butpotentially catastrophic complication of open heartsurgery, occurring in 0.06% of cardiac operations andresulting in 48% operative mortality.1,2 Any aortic orperipheral vessel manipulation during cardiac surgerycould be a source of dissection, including femoral cannu-lation, cross-clamps, proximal anastomotic sites, andeven intra-aortic balloon pumps. The endovascularapproach has made advances as an alternative treat-ment for aortic disease. The apex of the left ventricle(LV) has gained popularity for introduction duringtranscatheter aortic valve implantation for overcominglimitations of the conventional femoral approach andsupra-aortic approach, either a carotid or axillaryartery.3-6 However, the apical approach for transcatheterthoracic endovascular aortic repair (TEVAR) is not wellknown. The patient consented to publication of thisreport.CASE REPORTA 66-year-old woman with hypertension was admitted withshortness of breath and dizziness secondary to severe mitralvalve regurgitation with P2 prolapse on March 30, 2011. Shehad been stable for the preceding 3 years, and surgical valverepair was planned because of the development of these newsymptoms. Minimally invasive mitral valve repair was performedwith antegrade cardioplegia on April 1, 2011. Before closure ofthe skin, transesophageal echocardiography (TEE) revealedgood performance of the repaired mitral valve without regurgi-tation but also showed a small, localized aortic dissection in theascending aorta without aortic insufficiency. Because of herstable hemodynamics and localized flap, the decision wasmade for conservative treatment. Three days later, computedtomography (CT) of the thoracic aorta (TA) showed a type Aaortic dissection at the sinotubular junction extending to at leastthe midabdomen, where the study was completed. The dissec-tion also extended into the innominate and left renal artery(LRA), with the LRA supplied by both the true and false lumens.Although there was a possibility for the disease to go on, thepatient did not want any further surgical treatment then. Sheremained stable with medical management and wasdischarged after 2 weeks.One month and 3 months later, CT of the thoracoabdominalaorta was performed in an outpatient setting and found nosignificant change of the type A aortic dissection but additionallyidentified extension into the aortoiliac bifurcation, probablyinvolving the proximal aspect of the left common iliac artery(LCIA; Fig 1). The false lumen diameter appeared unchanged. Dur-ing the postoperative period, she complained of some fatigue onambulation and left leg claudication. Because of extension ofdissection with symptoms and refusal of additional surgery, itwas decided to proceed with transapical TEVAR (TaTEVAR).Informed consent was obtained, and we were asked to proceedwith the procedure. The TaTEVAR was performed on August 25,2011 (Fig 2). After preparation of both groins for vascular accessand the level of the fifth intercostal area for a left anterior thora-cotomy, a TEE probe was placed. The cardiothoracic teamexposed the pericardium and apex of the LV through a left ante-rior thoracotomy. A double purse-string suture was placed at thedimple of the LV. The LV was then punctured with a 0.018-inchsingle-wall needle by the interventional radiology team. A super-stiff wire was advanced into the proximal descending TA. TheFrom the Division of Interventional Radiology,a and Division of CardiothoracicSurgery,d Miami Cardiac and Vascular Institute, Miami; the Department ofMedical and Population Health Sciences Research, Herbert Wertheim Col-lege of Medicine, Florida International University, Miamib; and the RegionalCardiovascular Center, Division of Cardiology, Department of Internal Medi-cine, Chungbuk National University Hospital, Cheongju.cAuthor conflict of interest: none.Correspondence: Barry T. Katzen, MD, Division of Interventional Radiology,Miami Cardiac and Vascular Institute, 8900 N Kendall Dr, Miami, FL 33176(e-mail: barryk@baptisthealth.net).The editors and reviewers of this article have no relevant financial relationships todisclose per the Journal policy that requires reviewers to decline review of anymanuscript for which they may have a conflict of interest.2468-4287 2018 The Authors. Published by Elsevier Inc. on behalf of Society for VascularSurgery. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).https://doi.org/10.1016/j.jvscit.2018.05.007257surgical team provided the partial closure of the LV with thepurse-string suture and dilated the track for the 20F sheath (W.L. Gore & Associates, Flagstaff, Ariz), which was advanced intothe LV. Two 32-  45-mm Gore Excluder cuffs were placed withinthe proximal TA through the transapical approach to successfullyexclude a proximal fenestration between the true and falselumens of the type A dissection (Fig 2, F). The left thoracotomywas closed with good hemostasis. To provide blood flow fromthe true lumen to the LRA, a 6-  14-mm Express (Boston Scien-tific, Marlborough, Mass) stent was deployed in the origin of theLRA (Fig 2, G). The inferior mesenteric artery (IMA) was occludedusing 6-  2-mm Tornado (Cook Medical, Bloomington, Ind)embolization coils to prevent retrograde blood flow into a falselumen and to attempt to completely cure it. Two 8-  38-mmAtrium covered stents (Maquet, Rastatt, Germany) were sequen-tially deployed into the abdominal aorta (AA; Fig 2, H). Afterrepeated angiography of the AA, the right groin was closedwith a percutaneous closure device. There was no evidence of im-mediate complications. Three days later, postprocedure CTdemonstrated two successfully placed stents within theascending TA with exclusion of the type A dissection and throm-bosis of the intrathoracic false lumen (Fig 3). There was persistentopacification of the false lumen from just above the level of theceliac artery to the LCIA, although it was significantly decreasedin comparison to pre-TEVAR examination. CT also demonstrateda thrombosed IMA and a widely patent stent from the truelumen to the LRA. She was discharged after a 1-week hospitalcourse.One year later, CT showed no evidence of residual dissectionand status post placement of stent graft devices in the AA withobliteration of the previously opacified false lumen without endo-leak (Fig 4). Involvement of the LCIA was no longer seen, the LRAstent was patent, and the IMA remained occluded status post coilembolization. The last follow-up CT scan, 4 years postoperatively,also showed full resolution of the dissection without complica-tion. She had good performance without related symptoms ather most recent outpatient visit in February 2018.DISCUSSIONManipulation and cross-clamping of the ascendingaorta with antegrade cardioplegia might be implicatedin this case. When localized dissection of the ascendingaorta was found on intraoperative TEE, the risk ofsequential surgical treatment was considered alongwith the risk of iatrogenic type A aortic dissection. Forconventional surgical treatment of this complication,the possibility of superimposed dissection, difficulty inobtaining alternative access for cardiopulmonarybypass, and, similarly, difficulties with cerebral andmyocardial protection related to either dissection-induced malperfusion or the unplanned need for alter-ation in cannulation site necessitated by the dissectionshould be considered. Because hemodynamic statuswas stable during the operation and the intraoperativeTEE showed a localized flap, conservative manage-ment was decided. Although the aortic dissectionFig 1. A-F, Computed tomography (CT) showed type A aortic dissection (arrows) arising from the sinotubularjunction and extending through the aortic bifurcation into the left common iliac artery (LCIA). F, The left kidneywas supplied by both the false and true lumens (*). There was no evidence of associated renal infarct.258 Kim et al Journal of Vascular Surgery Cases and Innovative TechniquesSeptember 2018progressed from the ascending aorta to involve theLCIA, IMA, and LRA, she nonetheless remained stable.We had ample time for discussion with the cardiotho-racic team and the patient’s family. Extensive strategicplanning of the procedure was also possible. Althoughmost pathologic processes involving the ascendingaorta or aortic arch are considered unamenable to cur-rent endovascular treatment, she had excessively highrisk for open repair because of recent heart surgeryand manipulation of the aorta. Importantly, it wasthought that transapical access would offer a moredirect, anatomically favorable approach to theascending aorta with the small caliber of the iliofe-moral arteries (5 to 6 mm), the tortuosity of the aorta,and the bulky devices commercially available in 2011.The apex of the LV is the “front door” to the arterialvascular system and as such has gained popularity inthoracic endovascular aortic valve repair.3-6 However,TaTEVAR is not well known. Although no access issueshave been described so far during TaTEVAR, complica-tions related to the transapical thoracic endovascularaortic valve repair remain a concern, including bleedingfrom the LV apex, formation of an LV apex pseudoaneur-ysm, and development of a late ventricular septaldefect.7-9 Our patient had no related symptoms and noevidence of complications on immediate CT, and afollow-up CT scan 4 years later showed full resolution ofthe dissection. The long-term follow-up in this case ofTaTEVAR for iatrogenic aortic dissection is highly uniqueand valuable.Fig 2. Transapical thoracic endovascular aortic repair (TaTEVAR) and sequential angioplasty of the left renalartery (LRA), distal aorta, and inferior mesenteric artery (IMA) were performed successfully. A-F, Successfulplacement of two Gore Excluder cuffs within the proximal thoracic aorta (TA) through a transapical approach toexclude a proximal fenestration between the true and false lumens. G, Placement of an LRA stent at the ostium.H, Deployment of two Atrium (Maquet) stents within the infrarenal abdominal aorta (AA) after coil embolizationof the IMA. I, A small amount of contrast material is visualized within the false lumen that does not extend alongthe length of the true lumen.Journal of Vascular Surgery Cases and Innovative Techniques Kim et al 259Volume 4, Number 3Fig 3. Post-transapical thoracic endovascular aortic repair (TaTEVAR) follow-up computed tomography (CT)findings. A, Demonstration of TaTEVAR of a type A dissection with patent coronary arteries and no significantinterval change in location of the Gore Excluder cuffs. B-G, Persistent opacification (arrow) of the abdominalportion of the false lumen beginning at the level of the superior mesenteric artery and extending inferiorlyadjacent to the infrarenal abdominal aortic stents. F, The dissection extends into the common iliac artery on theleft side without significant interval change compared with preprocedure imaging. B and G,Widely patent renalarteries bilaterally including a stent within the proximal aspect of the left renal artery (LRA) extending from thetrue lumen into the renal artery.Fig 4. Most recent follow-up computed tomography (CT) findings on November 5, 2015. A-E, No significantresidual dissection present. C, D, and E, Resolution of the false lumen opacification seen on previous exami-nations within the abdominal portion of the dissection. B, D, and E, Patent left renal artery (LRA) stent.260 Kim et al Journal of Vascular Surgery Cases and Innovative TechniquesSeptember 2018CONCLUSIONSWe report a case of a 66-year-old woman with the rarecomplication of iatrogenic type A aortic dissection afterminimally invasive mitral valve repair. Althoughshe remained stable for 3 months on conservative man-agement, our patient was managed successfully withTaTEVAR and remained fully resolved 4 years later.REFERENCES1. Williams ML, Sheng S, Gammie JS, Rankin JS, Smith PK,Hughes GC. Aortic dissection as a complication of cardiacsurgery: report from the Society of Thoracic Surgeons data-base. Ann Thorac Surg 2010;90:1812-6.2. Januzzi JL, Sabatine MS, Eagle KA, Evangelista A,Bruckmann D, Fattori R, et al. Iatrogenic aortic dissection. AmJ Cardiol 2002;89:623-6.3. Rodés-Cabau J. Transcatheter aortic valve implantation: cur-rent and future approaches. Nat Rev Cardiol 2011;9:15-29.4. Lichtenstein SV, Cheung A, Ye J, Thompson CR, Carere RG,Pasupati S, et al. Transapical transcatheter aortic valveimplantation in humans: initial clinical experience. Circulation2006;114:591-6.5. Ye J, Cheung A, Lichtenstein SV, Carere RG, Thompson CR,Pasupati S, et al. Transapical aortic valve implantation inhumans. J Thorac Cardiovasc Surg 2006;131:1194-6.6. Blumenstein J, Van Linden A, Arsalan M, Moellmann H,Liebtrau C, Walther T, et al. Transapical access: current statusand future directions. Expert Rev Med Devices 2012;9:15-22.7. Kammler J, Steinwender C, Leisch F. False left ventricularapical aneurysmda rare complication after transapical aorticvalve replacement. J Invasive Cardiol 2011;23:534-5.8. Miranda N, Araji OA, Gutiérrez-Martín MA, Rodríguez-Caulo EA, Barquero JM, Valenzuela LF. Spontaneous closureof pseudoaneurysm after transapical aortic valve implanta-tion. Ann Thorac Surg 2011;92:729-31.9. Massabuau P, Dumonteil N, Berthoumieu P, Marcheix B,Duterque D, Fournial G, et al. Left-to-right interventricularshunt as a late complication of transapical aortic valveimplantation. JACC Cardiovasc Interv 2011;4:710-2.Submitted Mar 12, 2018; accepted May 30, 2018.Journal of Vascular Surgery Cases and Innovative Techniques Kim et al 261Volume 4, Number 3

Transapical endovascular repair of iatrogenic type A aortic dissection

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Transapical endovascular repair of iatrogenic type A aortic dissection

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