Emergent treatment of aortic rupture in acute type B dissection

Abstract

Massive left hemothorax is a rare and dramatic complication of acute type B aortic dissection. The primary endpoint is to treat the aortic rupture, stop the bleeding and stabilize the hemodynamic status, with the aim to prevent mortality and major cardiac, cerebral, visceral and renal complications. Thoracic endovascular repair (TEVAR) is the most frequent management, although its planning, in these emergent patients, may be very difficult and sub-optimal imaging may result at post-operative examination (CT and MRI). In case of TEVAR is not the definitive treatment of the aortic disease, a second stage surgical management can be performed in elective status, in a patient with a total clinical recover. In acute and dramatic circumstances, like ruptured type B dissection, TEVAR is a valid and suitable bridge procedure to open surgery, reducing the overall risk for mortality and major complications.

Keywords: Acute type B dissection; aortic rupture; frozen elephant trunk; thoracic endovascular repair (TEVAR).

Figure 1

Ruptured acute type B dissection with massive left hemothorax.

Figure 2

Percutaneous approach avoids the surgical cut-down of the femoral artery.

Figure 3

Endograft deployment to cover the entry tear and treat the aortic rupture.

Figure 4

Vascular plug positioning to avoid type 2 endoleak from left subclavian artery.

Figure 5

Massive hemothorax drainage via left thoracotomy.

Figure 6

Partial apposition of the proximal segment of the endograft (bird beak) favoring type Ia endoleaks.

Figure 7

Opened aortic arch.

Figure 8

Stent-graft cutting.

Figure 9

Outer Teflon felt positioning.

Figure 10

Endograft fixing using Teflon felt stiches.

Figure 11

Distal graft-endograft anastomosis.

Figure 12

Island technique.