Case Report
A 46-year old otherwise healthy individual man experienced sudden onset
of severe
thoracolumbar pain with radiation to both lower extremities during
climactic sexual intercourse.
The IRB waived the right for any formal review. He noticed weakness and
rigidity in both lower
extremities that he initially attributed to spasm.
There was no family of aortic aneurysm or dissection. Furthermore, when
he arrived at our
emergency room, he was in agonizing lower extremity pain refractory to
pain medications. A
computed tomography angiogram (CTA) confirmed a type A aortic dissection
extending from
the aortic root to the right common femoral artery (CFA). The dissection
flap extended
superiorly into bilateral subclavian and axillary arteries and origins
of both common carotid
arteries, which remained patent. The celiac, superior mesenteric, and
right renal artery were
perfused by the true lumen, and a false patent lumen extending into the
left renal artery was
noticed.
At the level of the aortic bifurcation into common iliac arteries, the
true lumen was markedly
narrowed, and minimal perfusion noticed into the false lumen. The left
common internal
iliac artery was noted to arise from the true lumen; however, it was
minuscule as well, reducing
flow significantly to the left lower extremity. There was a monophasic
Doppler signal on the left
left while and an absent Doppler signal on the right femoral artery. He
was hemodynamically
stable during the transfer to the operating room.
After general anesthesia and intubation, the left and right CFAs were
exposed via a transverse
infra-inguinal cut-down. After partial heparinization, a mid-portion of
a 10-mm Dacron fabric
graft was anastomosed to the left CFA in a side-to-side fashion. This
end was connected to the
arterial inflow limb of the cardiopulmonary bypass (CBP) machine circuit
(Figure1). A clamp
was placed on the free end. This graft served to perfuse both the
systemic circulation as well as
perfuse the left and lower extremity. The other end of the graft was
brought through a suprapubic
tunnel and sewn to right CFA beyond where the aortic dissection flap had
terminated. During
this tunneling, sternotomy and caval cannulation, CPB was initiated
following full
heparinization. Repair of aortic dissection with the replacement of hemi
aortic arch using a 32
mm Dacron graft was performed with 18 Celsius of 20 minutes circulatory
arrest and retrograde
cardioplegia. The aortic valve commissures were suspended as well. After
completing the aortic
dissection repair, lower extremity anastomosis, and expeditious
separation of CPB, we noticed
suboptimal perfusion to the right lower extremity despite adequate
systemic hemodynamics and
cardiac function. We had high suspicion that aortic dissection flap most
likely progressed and
resulted in significant flow reduction into both CFA.
Another possibility was that the abdominal aorta dissection flap could
have now occluded flow
to both iliac arteries. The patient was not in a hybrid room to
determine exact etiology, nor did
we have the technical expertise to perform an acute dissection flap’s
fenestration. We determined
that extra-anatomic arterial perfusion was necessary to perfuse the
limbs because of persistent
lower extremity malperfusion. An 8-mm ring reinforced
Polytetrafluoroethylene
(PTFE) graft was anastomosed to the perfused right axillary artery true
lumen and the end to the
proximal origin of the right femoral. After protamine reversal, a
standard 4-compartment
fasciotomy was performed on the index limb to prevent compartment
syndrome. The patient’s
postoperative course was notable for rhabdomyolysis and non-oliguric
acute renal failure, which
recovered fully without dialysis. The patient recovered without any
neurological deficit. He had
palpable distal pulses throughout in all four extremities at 2weeks
discharge to rehabilitation.
The patient has been followed up for 4 years and remains fully
functional, in full-time
employment (Figure 2).