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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