Case Report
A 53-year-old man came to our center. He complained of chest pain and
shortness of breath for 9 days. Computed tomography (CT) scan showed an
aortic arch aneurysm with a PAU in the descending aorta, right pleural
effusion and right lower lobe atelectasis (Figure 1A, 1B). The PAU was
detected in the descending aorta at about 100 mm from the left
subclavian artery on CT scan. We had taken active medical treatment for
him, including anti-infection, red blood cell transfusion, analgesia,
anti-hypertension. 10 days later, coronary CT scan showed that the
number of PAU increased and diameter of PAU elevated (Figure 1C). And he
underwent open surgery one day later.
Under hypothermic circulatory arrest, we performed TAR with a
four-branched vascular graft (28×90mm; Terumo, Vascutek Limited,
Renfrewshire, UK) after a FET stent (28×120mm; Cronus, MicroPort
Endovascular Shanghai Co, Ltd, China) was deployed into the descending
aorta under direct vision. After TAR with FET, the arterial pressure of
the left radial artery was higher than that of the left dorsalis pedis,
with a difference of about 40 mmHg. We performed aortography via the
right femoral artery. However, it was very difficult for the guidewire
to move forward. And aortography only showed the narrow thoracic aorta
resembled a thin line (Figure 2A). Then we had to perform antegrade
aortography via one branch stump of the vascular graft. Only
thoracoabdominal aorta, bilateral intercostal arteries and lumbar
arteries could be found from the scan, while the celiac axis, superior
mesenteric artery, and renal arteries disappeared (Figure 2B). We
comprehensively analyzed that the tip of the FET had been inserted into
the PAU and caused iatrogenic aortic dissection. The true lumen of
thoracoabdominal aorta was totally obliterated and viscera were
ischemic. We performed ascending aorta-right femoral artery bypass at
once, but the true lumen of aorta did not dilate. Then we performed
endovascular thoracoabdominal aortic fenestration to connect the true
lumen and the false lumen (Figure 2C). And a stent graft (28×80mm;
Valiant, Medtronic Vascular, Santa Rosa, CA, USA) was retrogradely
deployed to the descending aorta to restore the perfusion of the true
lumen (Figure 2D). After that, the radial artery and the dorsalis pedis
pressures were equal. But these procedures were complicated, and it took
about four hours to complete these procedures. During this period, the
visceral including liver, intestine and kidneys were ischemic.
Progressive lactic acidosis developed during operation. The patient
received bedside hemofiltration intraoperatively. After he was returned
to the intensive care unit, the hemodynamics deteriorated quickly. And
the patient died of multiorgan failure on the 1stpostoperative day.