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The case of patient C., 62 years old

He was admitted to the emergency department on 12/13/2018 at 20:22 with complaints of severe pain behind the sternum, with irradiation to the epigastric region, left arm, interscapular region and small pelvis, nausea, dizziness, severe weakness. The condition gradually worsened, hemodynamics on tonic support, patient in stupor, oxygenation 75% on inhalation of O2. According to relatives, he became acutely ill on 12.12.2018 at about 18.00, when, while doing physical exercises at home (lifting dumbbells), there was intense pain behind the sternum radiating to the left arm, epigastric region, interscapular region and small pelvis. He called an ambulance and was taken to the city hospital. Data for ACS were not identified, and therefore hospitalization was not offered. Upon arrival home, the patient’s condition did not improve, pain persisted, nausea and severe weakness appeared. The emergency room was re-called, with a diagnosis of acute pancreatitis delivered to the surgical department of another city hospital. Against the background of the therapy, the patient’s condition continued to remain severe, without positive dynamics. At 05:00 on 12/14/2018, the condition worsened sharply, chest pain increased against the background of a fall in blood pressure, and therefore he was transferred to the ICU. Performed MSCT angiography, revealed hemotamponade aortic dissection type A (Ia), rupture in the ascending region.

MSCT: dissection type I with hemotamponade
3D reconstruction of the aorta: extravasation of contrast into the pericardium.

Surgical tactics: Benthal’s operation and arch prosthetics according to the hemiarch technique. Connection of the artificial blood circulation apparatus through the right subclavian artery. INTRAOPERATIVE: about 400 ml of blood with clots was released from the pericardium under pressure. Dissection extends to the brachiocephalic trunk and extends to its bifurcation and then passes to the left common carotid artery. A decision was made to cool the body to 25 ° C. Stopping blood circulation in the lower half of the body for 14 minutes to apply an open anastomosis according to the hemiarch technique. Visually, no fenestrations in the area of ​​the arch were detected.

In the postoperative period, the patient developed frequent ischemic transient attacks, manifested by visual impairments and coordination disorders. CT angiography was performed on 12/19/18 (5 days after resection of the AoC and aneurysm).

the dissection is persists instantly from the distal anastomosis
3D reconstruction, dissection persists

CT result: Aorta at the level of the proximal arch: 35 mm (true lumen 23 mm, false lumen 11 mm). The left CCA and left subclavian arteries originate from the false lumen. Partial thrombosis of the false lumen in the aortic arch.

If the cause of TIA in the immediate postoperative period is incipient thrombosis of the false lumen from which the left carotid artery originates, then the prospect of a severe neurological deficit in the patient in the near future is extremely high. Due to the compromised brachiocephalic arteries, the patient has no options for further endovascular treatment of the remaining dissected aorta.

bald arch technique applied

Reoperation: reimplantation of the brachiocephalic arteries into a bifurcation prosthesis sewn into the ascending aorta prosthesis. Bald arch reconstruction (debranching). (21.12.18)

All brachiocephalic arteries are outside the dissection!

The patient was discharged home on day 14 for rehabilitation. His visual impairment persisted. MRI shows multiple small foci of ischemic brain damage. We still have the following unresolved issues:

  • What to do with the remaining aortic dissection?
  • What kind of treatment to take? Observation? Endo prosthetics? If yes, then when? How many grafts? Should the left kidney be sacrificed if the left renal artery departs from the false lumen? (false lumen can obstruct the orifice of the renal artery and lead to kidney death)

Our proposal for him was the installation of two stent grafts from the distal anastomosis to the diaphragm 3 months after discharge from the hospital to protect the aorta from remodeling (aneurysmal transformation in the future). For various reasons, the patient did not follow our recommendations and remained under observation. Seems not in vain!

3D reconstruction of the aorta one year after surgery
CTA of the aorta one year after surgery (horizontal view)
CTA of the aorta one year after surgery (frontal view)
CTA of the aorta one year after surgery (sagital view)

On CT angiography a year after the operation, the patient had occlusion of the false lumen of the dissected aorta down to the lower third of its descending part. Thus, the result that we wanted to achieve with the use of endo prostheses was achieved spontaneously. At the same time, the patient retained the function of both kidneys. The question remains, what will happen to the dissected part of the aorta below the diaphragm in the future? Let’s wait and watch………