K.E.M. Radiology
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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Contributed by : Milan Talati
Thoracic endovascular aortic repair (TEVAR) in a case of dissected thoracic aortic aneurysm with contained rupture.
Introduction:
The sine qua non of the classic aortic dissection is a tear in the intima that allows pulsatile blood to penetrate the vessel wall. A cleavage plane develops between the layers of the intima and media and allows a column of blood to form within the intramural space, composing the false lumen. The dissection may propagate in an antegrade or retrograde direction or in both directions. The location of the intimal tear usually occurs in a compromised region of the vessel with underlying mural degeneration. Common causes include long-standing hypertension, connective tissue disorders, and trauma. (1,2,3)
It is important to differentiate the primary or entry intimal tear from the secondary or re-entry tear(s). Approximately two thirds of primary tears occur in the ascending aorta, with more than half of these located within the first 2 cm of the ascending aorta. The next most common site of the primary tear is the isthmus of the aorta just beyond the ligamentum arteriosum (4,5). These regions are presumably subjected to the greatest hemodynamic stress, which makes them more susceptible to injury. In either location, these tears are 5 times more likely to be transverse in orientation rather than longitudinal. Other sites of primary tears include the descending thoracic aorta, aortic arch, and abdominal aorta, with multiple primary tears seen in 8% of cases. (6).
Case presentation:
A 65-years old man presented with history of backache, vomiting since four to five days. His pain was associated with breathlessness. The patient was known hypertensive since eight years and on regular medications for the same. There was no history of any past hospital admission. Clinical examination of his respiratory and cardiovascular system was normal. Chest radiograph was done and showed widening of mediastinum with unfolding of aorta, based on abnormal chest radiograph CT aortogram was performed. CT aortogram showed dissection with thrombosis of false lumen saccular outpouching arising from arch of aorta distal to the origin of left subclavian artery with mediastinal hematoma and contrast extravasation which gradually increased on delayed images (Fig 1a,1b)
Fig. 1 :
1a- Axial CT image of Aortogram (arterial phase) shows dissection and saccular aneurysm arising from arch of aorta distal to the origin of left subclavian artery with mediastinal hematoma.
1b- Axial CT image of Aortogram (delayed phase) shows contrast extravasation in the mediastinum with surrounding mediastinal hematoma.
1c- Axial CT image of Aortogram delayed phase shows extension of extravasated contrast up to the neck.
1d- MPR image showing a saccular outpouching arising from arch of aorta distal to the origin of left subclavian artery.
Fig. 2 2a- The saccular aneurysm with dissection is seen arising distal to left subclavian artery, however periaortic hematoma is seen extending upto its origin.
2b- Axial CTscan at the level of neck shows prominent right vertebral artery as compared to left.
The procedure was performed under general anaesthesia. Left Common femoral artery access was obtained with a 5F vascular sheath. A 5F marker pigtail catheter was positioned in the aortic arch with the help of a glide wire, and arch aortogram was obtained and findings confirmed. Subsequently, right common femoral artery arteriotomy was performed and a 5F sheath inserted, through which a Lunderquist wire was inserted up to the level of the aortic arch.
A metallic stent graft (Ankura TAA, Lifetech) was then inserted on the wire and subsequently unloaded. Repeat aortogram showed adequate placement of the stent, with no filling of the aneurysmal sac and filling of left subclavian artery by steal of blood from right vertebral artery. The procedure was clinically uneventful. Vital monitoring done throughout the procedure was uneventful. Post procedure, patient tolerated the procedure well.
Figure 3: 3a- Axial CT image of Aortogram arterial phase shows mediastinal hematoma.
3b- Axial CT image of Aortogram delayed phase shows progressive increased extravasated contrast.
Fig. 4, DSA image showing codominance of bilateral vertebral arteries.
Fig. 5: A,B,C- Axial CT image at the level above the arch, at the level of arch, at level below the arch, shows near complete resolution of mediastinal hematoma
Video 1: DSA of arch of aorta shows saccular aneurysm arising distal to left subclavian artery.
Video 2: DSA of arch of aorta post deployment of stent graft distal to the common origin of brachiocephalic artery and left common carotid artery shows isolation of aneurysm from the main circulation and retrograde filling of left subclavian artery from left vertebral artery.