Catheterization and Cardiovascular Diagnosis 26:130-135 (1992)
Percutaneous Fenestration of Dissecting lntima With a Transseptal Needle. A New Therapeutic Technique for Visceral Ischemia Complicating Acute Aortic Dissection Shigeru Saito, MD, Hidekazu Arai, MD, Kunikane Kim, MD, Naoto Aoki, MD, and Masanobu Tsurugida, MD Noncardiac visceral Ischemia Is a major complication with acute aortic dissection and is caused by obstruction of the major visceral arteries by dissecting intima. Two patients with this Condition underwent emergency percutaneousfenestration of dissecting Intlma, and the blood flow to the lower extremity and kidney was restored. A transseptal needle and peripheral angloplasty balloon catheter were used for fenestration. There were no associatedcomplications in either patient. One patient was treated medically and another had ascending aortic replacement surgery the day after percutaneous fenestration. Clinical follow-up of 10 and 5 months, respectively, revealed good clinical outcomes. Percutaneous fenestration should be considered the treatment of choice for visceral ischemia due to acute aortic dissection. o 1092 Wiiey-uu, Inc. Key words: acute aortic dissection, Ischemic complications
INTRODUCTION
CASE ONE
Acute aortic dissection is still a serious condition. Ischemia of organs other than the heart which is one of a major complication is caused by obstruction of the major visceral arteries by dissection of the intima. It has been reported to occur in 33% of cases [ 11, and the mortality is reported to be 51%, which is significantly higher than the mortality of 29% in patients without such complications [ 11. Emergency surgical procedures to restore blood flow is necessary in patients with impending stroke, paraplegia, renal failure, bowel or lower extremity ischemia. However, the mortality rate in patients treated with emergency surgery for acute aortic dissection combined with these procedures is reported to be seven times higher than in those without the complications [ 1,2]. Therefore, open fenestration or bypass surgery without aortic replacement during the acute phase is selected in some institution [3]. So if the reconstruction procedures other than surgical fenestration or bypass for visceral ischemia are possible, it is expected that the mortality of these complicated cases will be decreased. Recently we applied a new nonsurgical technique for blood flow restoration in two patients with acute aortic dissection complicated with acute ischemia in the lower extremities and kidneys, and achieved good results. We named this technique “percutaneous fenestration of dissecting intima.” In this article, we describe these two cases and describe this new effective technique.
A 54-year-old man with medically treated hypertension and previous aortic valve replacement for aortic regurgitation and a history of anterior myocardial infarction presented with back and leg pain and bilateral pulseless femoral arteries in December 1990. His electrocardiogram showed a Q, pattern in leads V1 to V3, and his chest roentgenogram a markedly dilated cardiac silhouette and the aortic mechanical valve. Our first impression from his clinical history and tests was that he had an acute saddle embolization of the abdominal aorta, and we took him immediately to the catheterization laboratory. A right transbrachial angiogram of the ascending aorta revealed a type I aortic dissection (Fig. IA). The false lumen was markedly enlarged below the aortic arch and the celiac, superior mesenteric and left renal arteries originated from it. Both common iliac arteries originated from the true lumen but were not visualized during ascending aortography and abdominal aortography of the true lumen (Fig. lB), because the true lumen
0 1992 Wiley-Liss, Inc.
From the Divisionof Cardiology. Shonan Kamakura Hospital, 1202-1 Yamazaki, Kamakura, Japan. Received November 7, 199 1. Address reprint requests to Shigeru Saito, MD, Division of Cardiology, Shonan Kamakura Hospital, 1202-1 Yamazaki, Kamakura 247, Japan.
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Fig. 2. Case one. Simultaneous pressure tracing of the ascending aorta (AoA) and the right femoral artery (RFA). (A) Just after blind puncture of the right femoral artery. Note that the femoral arterial wave looks nearly flat and Its mean pressure is 50 mm Hg. (B) Atler percutaneous fenestration. Fig. 1. Case one. Aortograms. (A) Right anterior oblique view of ascending aortogram. Arrows denote the dissecting intima. (B) True lumen abdominal aortogram. Note that the right renal artery originates from the true lumen. (C) Left anterior oblique view of aortic arch. Note that the true lumen is compressed by the enlarged false lumen.
was nearly completely occluded due to the compression by the enlarged false lumen beyond the origin of the left subclavian artery (Fig. 1C). We punctured blindly the pulseless right femoral artery, the pulse wave of which was nearly flat and the pressure was 50 mm Hg while that in the ascending aorta it was 160/83 (1 11) mm Hg (Fig. 2A). After a 6F multipurpose catheter with a 0.038inch J-guide wire was easily advanced through the right femoral artery to the true lumen of the thoracic aorta, the right femoral arterial pressure increased to 98/80 (90) mm Hg and the pulsations in the left femoral artery also became palpable. However, when the catheter was pulled out, the femoral blood pressure decreased again and the left femoral pulse disappeared. These angiographic findings showed his aortic anatomy to be as seen in Figure 3A, and it was thought that a fenestration procedure was required in order to save his lower extremities and right kidney. However, his history of aortic valve replacement and anterior myocardial infarction and a marked cardiomegaly let us to decide that emergency surgery was too dangerous. Instead of surgery, percutaneous fenestration of the obstructing dissecting intima was tried in order to restore blood flow.
A
Fig. 3. Case one. Diagram of the aortic dissection. Dark areas are false lumen. (A) Before percutaneousfenestration. Note that the celiac, left renal and superior mesenteric arteries originate from the false lumen. (B) After percutaneous fenestration.
An 8F Mullin’s dilator (C.R.Bard) with a J-guide wire was inserted from the right femoral artery to the true lumen of the abdominal aorta, then a transeptal needle was passed through it. The left femoral artery was punctured and a 6F multipurpose catheter was inserted into the true lumen of the abdominal aorta for reference. The
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Fig. 4. Case one. Percutaneousfenestration. (A) First attempt at puncture, failed. (B) Successful puncture of dissecting intima with a transseptal needle in left anterior oblique view. Note the reference catheter inserted through the iefl femoral artery. (C) Guide wire into the false lumen through Muiiin’s dilator. (D) Fenestration by a balloon catheter of 7 mm in diameter.
Fig. 5. Case one. Abdominal aortogram 3 months later revealed good blood flow to the both iliac arteries.
first attempt to puncture the dissecting intima just above the iliac bifuraction failed because the tip of the needle could not be positioned properly against the dissecting intima (Fig. 4A). The second attempt was made successfully a little below the origin of the renal arteries in the left anterior oblique fluoroscopic view (Fig. 4B). Dye injection through the transseptal needle confirmed that the tip had entered the false lumen. After a gentle push of the Mullin’s dilator, the transseptal needle was exchanged to a 0.032-inch J-guide wire which was passed from the right femoral artery into the false lumen of the ascending aorta through the dissecting intima and the true lumen (Fig. 4C).Then a peripheral angioplasty balloon catheter of 7 mm in diameter (ProFlex5) was advanced along the guide wire into the abdominal false lumen. The balloon was inflated against the dissecting intima at 6 atmospheres, pushed in, and pulled back several times in order to tear off the dissecting intima and make a fenestration (Fig. 4D).After that, the femoral blood flow of both sides resumed, and right femoral blood pressure increased (Fig. 2B). The blood pressure in the femoral arteries was continuously monitored through the sheath introducers, which were removed 2 days after percutaneous fenestration. A P-adrenergic receptor blocking agent was carefully administered. The Fig. 6. Case two. Emergency aortography. (A) Ascending aor- aortogram, which was taken 3 months later, revealed tography showed typei aortic dissection. (6) The celiac, left good blood flow into the iliac arteries through the fenrenal, and superior mesenteric arteries originate from the true lumen. (C) The right external iliac artery is occluded. (D) Dye estration (Fig. 5). The patient has been in good clinical injection from the catheter inserted into the true lumen of the condition for more than 10 months, and his last roentabdominal aorta through the right femoral artery. genogram shows no enlargement of the thoracic aorta.
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t RF A Fig. 8. Case two. Diagram of the aortic dissection. Dark areas are false lumen. (A) Before percutaneous fenestration. (B) After percutaneous fenestration.
Fig. 7. Case two. Simultaneous pressure tracing of the ascending aorta (AoA) and the right femoral artery (RFA). (A) Just after blind puncture of the right femoral artery. (B) After percutaneous fenestration.
tured a little above the iliac bifurcation with only one attempt. When the tip of the needle penetrated the intima, some soft resistance was felt. After the correct position of the needle was ascertained by dye injection CASE TWO through the needle (Fig. 9A), the dilator and needle were A 56-year-old woman with a history of mild hyper- pushed slightly into the false lumen (Fig. 9B). After the tension presented with severe chest and upper back pain needle was exchanged to a 0.032-inches J guide wire, the followed by lower back pain and right leg pain in May dilator was advanced to the false lumen of the thoracic 1991. The right femoral pulse was not palpable. An aorta (Fig. 9C). Then the dilator was exchanged to a emergency right transbrachial aortography revealed type- peripheral angioplasty balloon catheter of 7 mm in diI aortic dissection and the occlusion of the right external ameter (ProFlexS). The balloon was inflated at 6 atmoiliac artery (Fig. 6A and C). The right renal artery orig- spheres against the dissecting intima, pulled back, and inated from the false lumen, and the celiac, superior pushed in several times in order to tear off the dissecting mesenteric and left renal arteries from the true lumen intima and make the fenestration (Fig. 9 0 ) . After this (Fig. 6B). The pulseless right femoral artery as punc- maneuver, the right femoral blood pressure increased tured blindly. The right femoral blood pressure wave was (Fig. 7B), and the abdominal aortogram of the true luflat and about 30 mm Hg compared to 170170 (107) rnm men revealed the restoration of blood flow through the Hg at the ascending aorta (Fig. 7A). Whereas a 6 F mul- fenestration into the right renal and external iliac arteries tipurpose catheter with J-guide wire could be easily ad- (Fig. 10). A f3-adrenergic receptor blocking agent was vanced into the true lumen of the abdominal aorta from administered, before performing the replacement surgery the right femoral artery, the right external iliac artery of the ascending aorta with a ringed artificial vessel graft could not be visualized by hand injection of dye from the following day. that catheter (Fig. 6D). From these angiographic findThe surgery was performed under total cardiopulmoings, the patient’s aortic anatomy was postulated to be as nary bypass with pump perfusion from the left femoral shown in Figure 8A. artery combined with occlusion of the aorta by a Fogarty Fenestration of the dissecting intima was thought to be aortic occlusion balloon which was inserted from the necessary in order to save her right leg and kidney. A 7F ascending aorta into the true lumen of the aortic arch. Mullin’s dilator was advanced into the true lumen of the During surgery it was seen that the blood flow into the abdominal aorta with a 0.032-inch J guide wire from the false lumen through the fenestration was adequate. Five right femoral artery. Then a transseptal needle was in- months after percutaneous fenestration and the replaceserted into the dilator. Under the left anterior oblique flu- ment of the ascending aorta she remains in good condioroscopic view, the dissecting intima was easily punc- tion.
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Fig. 9. Puncture with a transseptal needle and Mullin’s dllator. (A) Puncture with a transseptal needle in the left anterlor oblique view. (B) Mullin’s dilator has been pushed into the false lumen. (C) Jgulde wire was inserted into the false lumen of the thoracic aorta. (D) Peripheral angioplasty balloon of 7 mm in diameter inflated to produce fenestration.
DISCUSSION The Need for Emergent Fenestration
Fig. 10. Case two. True lumen angiogram of the abdominal aorta with the catheter insemd through the right femoral artery after percutaneous fenestration provides good visualization of the rlght renal and external iliac arteries.
ing intima was the only possible treatment to save his life. In case two, replacement of the ascending aorta without fenestration might have induced the infarction of the right kidney, because the right renal artery had its origin from the false lumen which had only entry from but no reentry into the aorta. Thus, it is apparent that percutaneous fenestration was effective and inevitable in these two cases.
As mentioned earlier, the incidence of noncardiac vascular complications associated with aortic dissection has been reported to be as high as 33% [ 11. These complications are caused by obstruction of the blood flow into Method of Percutaneous Fenestration and the major aortic branches by the dissecting intima. Es- Possible Complications pecially in the acute phase of dissection, peripheral ischWhile spontaneous resolution of lower extremity ischemia such as in the lower extremities, kidneys, or intes- emia after catheter manipulation in the iliac artery or tines may cause serious problems for treatment [8]. In a abdominal aorta has been reported in two articles [6,7], series of 527 surgically treated cases of aortic dissection, only two cases of percutaneous fenestration for visceral 13% of patients with type I and 6% of those with type ischemia has been reported so far [9, lo]. These papers IIlb dissection had peripheral ischemia [5]. In another describe the penetration of the dissecting intima with the series of 325 cases of aortic dissection, 38 patients (12%) use of a guide wire and a guide catheter as late as 1 demonstrated some degree of lower extremity ischemia, month [9] or 27 months [lo] after acute aortic dissection. and one-third of these required a direct approach on the The present paper is the first to describe percutaneous abdominal aorta or iliofemoral segments to restore cir- fenestration with a transseptal needle during the acute culation [ l ] . In both of the patients described here, if phase of aortic dissection. The possible complications of emergency fenestration had not been performed, the percutaneous fenestration with a transseptal needle inright kidney might have been infarcted, and the lower clude perforation of the aortic wall, extension of dissecextremities might have become necrotic. Particularly in tion, and distal embolization. It can be thought that the case one, almost all surgical interventions were contrain- aortic wall puncture with such a needle as thin as a transdicated because of the history of aortic valve replacement septa1 one is relatively safe, because the frequency of and myocardial infarction and the presence of marked major complications associated with diagnostic transcardiomegaly. So, percutaneous fenestration of dissect- lumbar aortography has been reported to be only about
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3% [ll-131. A transseptal needle is thought to be supe- of choice in selected patients with visceral ischemia due rior to a guide wire for the puncture of a dissecting in- to acute aortic dissection. tima, because dye injection from the tip is possible only in the former. To avoid aortic wall perforation by a larger REFERENCES catheter, appropriate fluoroscopic views, which can be I . Cambria RP, Brewster DC, Gertler J , Moncure AC, Gusberg R, relatively easily obtained by aortography in multiple proTilson D, Darling RC, Hammond G , Megerman J , Abbott WM: jections, should be selected during needle puncture, and Vascular complications associated with spontaneous aortic dissection. J V a x Surg 7:199-209, 1988. dye injection should be done from the tip of the needle before the Mullin’s dilator is pushed into the opposite 2. Miller DC, Mitchell S, Oyerk PE, Stinson EB, Jamieson SW, Shumway N E Independent determinants of operative mortality lumen. It is thought not to be very important whether the for patients with aortic dissections. Circulation 70: 153-164, puncture is done from the true to the false or the false to 1984. the true lumen, because in case one the latter, and in case 3. Elefteriades JA, Hammond GL, Gusberg RJ. Kopf GS, Baldwin JC: Fenestration revisited: A safe and effective procedure for two the former occurred. The theoretical risks of distal descending aortic dissection. Arch Surg I25:786-79O, 1990. embolization or extension of the dissection cannot be 4. Schoon IM, Holm J, Sudow G: Lower-extremity ischemia in eliminated, but neither happened in our two cases, and aortic dissection: Report of three cases. Scand J Thor Cardiovasc even if they do, they are thought to be acceptable risks in Surg 19:93-95, 1985. such acute complicated settings, compared with the risks 5. DeBakey ME, McCollum CH. Crawford ES, Moms GCJ, Howell J, Noon GP. Lawne G: Dissection and dissecting aneurysms of of combined surgical aortic replacement and fenestrathe aorta: Twenty year follow-up of five hundred and twentytion.
Mechanism of the Restoration of Blood Flow to Lower Extremities In both of our patients, the puncture of the dissecting intima was done above the iliac bifurcation. If the window made by percutaneous fenestration allows blood to pass only into the occluded lumen, the blood flow to the lower extremities might not be restored. The reconstruction of the distal aorta and redirection of blood flow into the true lumen [3] as a result of the decompression of the false lumen after percutaneous fenestration are possible mechanisms for the restoration of blood flow to the lower extremities.
CONCLUSION
On the basis of the encouraging results observed in our patients, we suggest that percutaneous fenestration with a transseptal needle should be considered the treatment
seven patients treated surgically. Surgery 92:1118-1134, 1982. 6. Shumacker HB, lsch JH, Jolly WW: Stenotic and obstructive lesions in acute dissecting thoracic aortic aneurysms. Ann Surg 1811662-669, 1975. 7. Shah PM, Clauss RH. Dissecting hematoma presents as acute lower limb ischemia: Diagnostic patient profile and management. J Cardiovasc Surg 24:649-653, 1983. 8. DeBakey ME, Cooley DA, Creech 0: Surgical considerations of dissecting aneurysm of the aorta. Ann Surg 142586-612. 1955. 9. Williams DM, Brothers TE, Messina LM: Relief of mesenteric ischemia in type IIIc dissection with percutaneous fenestration of the aortic septum. Radiology 174:450-452, 1990. 10. Shimshak TM, Giorgi LV, Hartzler GO: Successful percutaneous transluminal angioplasty of an obstructed abdominal aorta secondary to a chronic dissection. Am J Cardiol61:486-487, 1988. 11. Bakal CW, Friedland RJ, Sprayregen S, Calligaro KD, Cynamon J . Veith FJ: Translumbar arch aortography: A retrospective controlled study of usefulness, technique, and safety. Radiology 178: 225-228, 1991. 12. Szilagyi DE, Smith RF, Elliot JPJ, Hageman JH: Translumbar aortography: A study of its safety and usefulness. Arch Surg 1121399-408, 1977. 13. Dorph S, Folke K: Complications in translumbar aortography: A comparion of direct needle puncture and aortic catheterization. Acta Radio1 12:750-756, 1973.
Percutaneous Fenestration of Dissecting lntima With a Transseptal Needle. A New Therapeutic Technique for Visceral Ischemia Complicating Acute Aortic Dissection Shigeru Saito, MD, Hidekazu Arai, MD, Kunikane Kim, MD, Naoto Aoki, MD, and Masanobu Tsurugida, MD Noncardiac visceral Ischemia Is a major complication with acute aortic dissection and is caused by obstruction of the major visceral arteries by dissecting intima. Two patients with this Condition underwent emergency percutaneousfenestration of dissecting Intlma, and the blood flow to the lower extremity and kidney was restored. A transseptal needle and peripheral angloplasty balloon catheter were used for fenestration. There were no associatedcomplications in either patient. One patient was treated medically and another had ascending aortic replacement surgery the day after percutaneous fenestration. Clinical follow-up of 10 and 5 months, respectively, revealed good clinical outcomes. Percutaneous fenestration should be considered the treatment of choice for visceral ischemia due to acute aortic dissection. o 1092 Wiiey-uu, Inc. Key words: acute aortic dissection, Ischemic complications
INTRODUCTION
CASE ONE
Acute aortic dissection is still a serious condition. Ischemia of organs other than the heart which is one of a major complication is caused by obstruction of the major visceral arteries by dissection of the intima. It has been reported to occur in 33% of cases [ 11, and the mortality is reported to be 51%, which is significantly higher than the mortality of 29% in patients without such complications [ 11. Emergency surgical procedures to restore blood flow is necessary in patients with impending stroke, paraplegia, renal failure, bowel or lower extremity ischemia. However, the mortality rate in patients treated with emergency surgery for acute aortic dissection combined with these procedures is reported to be seven times higher than in those without the complications [ 1,2]. Therefore, open fenestration or bypass surgery without aortic replacement during the acute phase is selected in some institution [3]. So if the reconstruction procedures other than surgical fenestration or bypass for visceral ischemia are possible, it is expected that the mortality of these complicated cases will be decreased. Recently we applied a new nonsurgical technique for blood flow restoration in two patients with acute aortic dissection complicated with acute ischemia in the lower extremities and kidneys, and achieved good results. We named this technique “percutaneous fenestration of dissecting intima.” In this article, we describe these two cases and describe this new effective technique.
A 54-year-old man with medically treated hypertension and previous aortic valve replacement for aortic regurgitation and a history of anterior myocardial infarction presented with back and leg pain and bilateral pulseless femoral arteries in December 1990. His electrocardiogram showed a Q, pattern in leads V1 to V3, and his chest roentgenogram a markedly dilated cardiac silhouette and the aortic mechanical valve. Our first impression from his clinical history and tests was that he had an acute saddle embolization of the abdominal aorta, and we took him immediately to the catheterization laboratory. A right transbrachial angiogram of the ascending aorta revealed a type I aortic dissection (Fig. IA). The false lumen was markedly enlarged below the aortic arch and the celiac, superior mesenteric and left renal arteries originated from it. Both common iliac arteries originated from the true lumen but were not visualized during ascending aortography and abdominal aortography of the true lumen (Fig. lB), because the true lumen
0 1992 Wiley-Liss, Inc.
From the Divisionof Cardiology. Shonan Kamakura Hospital, 1202-1 Yamazaki, Kamakura, Japan. Received November 7, 199 1. Address reprint requests to Shigeru Saito, MD, Division of Cardiology, Shonan Kamakura Hospital, 1202-1 Yamazaki, Kamakura 247, Japan.
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Fig. 2. Case one. Simultaneous pressure tracing of the ascending aorta (AoA) and the right femoral artery (RFA). (A) Just after blind puncture of the right femoral artery. Note that the femoral arterial wave looks nearly flat and Its mean pressure is 50 mm Hg. (B) Atler percutaneous fenestration. Fig. 1. Case one. Aortograms. (A) Right anterior oblique view of ascending aortogram. Arrows denote the dissecting intima. (B) True lumen abdominal aortogram. Note that the right renal artery originates from the true lumen. (C) Left anterior oblique view of aortic arch. Note that the true lumen is compressed by the enlarged false lumen.
was nearly completely occluded due to the compression by the enlarged false lumen beyond the origin of the left subclavian artery (Fig. 1C). We punctured blindly the pulseless right femoral artery, the pulse wave of which was nearly flat and the pressure was 50 mm Hg while that in the ascending aorta it was 160/83 (1 11) mm Hg (Fig. 2A). After a 6F multipurpose catheter with a 0.038inch J-guide wire was easily advanced through the right femoral artery to the true lumen of the thoracic aorta, the right femoral arterial pressure increased to 98/80 (90) mm Hg and the pulsations in the left femoral artery also became palpable. However, when the catheter was pulled out, the femoral blood pressure decreased again and the left femoral pulse disappeared. These angiographic findings showed his aortic anatomy to be as seen in Figure 3A, and it was thought that a fenestration procedure was required in order to save his lower extremities and right kidney. However, his history of aortic valve replacement and anterior myocardial infarction and a marked cardiomegaly let us to decide that emergency surgery was too dangerous. Instead of surgery, percutaneous fenestration of the obstructing dissecting intima was tried in order to restore blood flow.
A
Fig. 3. Case one. Diagram of the aortic dissection. Dark areas are false lumen. (A) Before percutaneousfenestration. Note that the celiac, left renal and superior mesenteric arteries originate from the false lumen. (B) After percutaneous fenestration.
An 8F Mullin’s dilator (C.R.Bard) with a J-guide wire was inserted from the right femoral artery to the true lumen of the abdominal aorta, then a transeptal needle was passed through it. The left femoral artery was punctured and a 6F multipurpose catheter was inserted into the true lumen of the abdominal aorta for reference. The
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Fig. 4. Case one. Percutaneousfenestration. (A) First attempt at puncture, failed. (B) Successful puncture of dissecting intima with a transseptal needle in left anterior oblique view. Note the reference catheter inserted through the iefl femoral artery. (C) Guide wire into the false lumen through Muiiin’s dilator. (D) Fenestration by a balloon catheter of 7 mm in diameter.
Fig. 5. Case one. Abdominal aortogram 3 months later revealed good blood flow to the both iliac arteries.
first attempt to puncture the dissecting intima just above the iliac bifuraction failed because the tip of the needle could not be positioned properly against the dissecting intima (Fig. 4A). The second attempt was made successfully a little below the origin of the renal arteries in the left anterior oblique fluoroscopic view (Fig. 4B). Dye injection through the transseptal needle confirmed that the tip had entered the false lumen. After a gentle push of the Mullin’s dilator, the transseptal needle was exchanged to a 0.032-inch J-guide wire which was passed from the right femoral artery into the false lumen of the ascending aorta through the dissecting intima and the true lumen (Fig. 4C).Then a peripheral angioplasty balloon catheter of 7 mm in diameter (ProFlex5) was advanced along the guide wire into the abdominal false lumen. The balloon was inflated against the dissecting intima at 6 atmospheres, pushed in, and pulled back several times in order to tear off the dissecting intima and make a fenestration (Fig. 4D).After that, the femoral blood flow of both sides resumed, and right femoral blood pressure increased (Fig. 2B). The blood pressure in the femoral arteries was continuously monitored through the sheath introducers, which were removed 2 days after percutaneous fenestration. A P-adrenergic receptor blocking agent was carefully administered. The Fig. 6. Case two. Emergency aortography. (A) Ascending aor- aortogram, which was taken 3 months later, revealed tography showed typei aortic dissection. (6) The celiac, left good blood flow into the iliac arteries through the fenrenal, and superior mesenteric arteries originate from the true lumen. (C) The right external iliac artery is occluded. (D) Dye estration (Fig. 5). The patient has been in good clinical injection from the catheter inserted into the true lumen of the condition for more than 10 months, and his last roentabdominal aorta through the right femoral artery. genogram shows no enlargement of the thoracic aorta.
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t RF A Fig. 8. Case two. Diagram of the aortic dissection. Dark areas are false lumen. (A) Before percutaneous fenestration. (B) After percutaneous fenestration.
Fig. 7. Case two. Simultaneous pressure tracing of the ascending aorta (AoA) and the right femoral artery (RFA). (A) Just after blind puncture of the right femoral artery. (B) After percutaneous fenestration.
tured a little above the iliac bifurcation with only one attempt. When the tip of the needle penetrated the intima, some soft resistance was felt. After the correct position of the needle was ascertained by dye injection CASE TWO through the needle (Fig. 9A), the dilator and needle were A 56-year-old woman with a history of mild hyper- pushed slightly into the false lumen (Fig. 9B). After the tension presented with severe chest and upper back pain needle was exchanged to a 0.032-inches J guide wire, the followed by lower back pain and right leg pain in May dilator was advanced to the false lumen of the thoracic 1991. The right femoral pulse was not palpable. An aorta (Fig. 9C). Then the dilator was exchanged to a emergency right transbrachial aortography revealed type- peripheral angioplasty balloon catheter of 7 mm in diI aortic dissection and the occlusion of the right external ameter (ProFlexS). The balloon was inflated at 6 atmoiliac artery (Fig. 6A and C). The right renal artery orig- spheres against the dissecting intima, pulled back, and inated from the false lumen, and the celiac, superior pushed in several times in order to tear off the dissecting mesenteric and left renal arteries from the true lumen intima and make the fenestration (Fig. 9 0 ) . After this (Fig. 6B). The pulseless right femoral artery as punc- maneuver, the right femoral blood pressure increased tured blindly. The right femoral blood pressure wave was (Fig. 7B), and the abdominal aortogram of the true luflat and about 30 mm Hg compared to 170170 (107) rnm men revealed the restoration of blood flow through the Hg at the ascending aorta (Fig. 7A). Whereas a 6 F mul- fenestration into the right renal and external iliac arteries tipurpose catheter with J-guide wire could be easily ad- (Fig. 10). A f3-adrenergic receptor blocking agent was vanced into the true lumen of the abdominal aorta from administered, before performing the replacement surgery the right femoral artery, the right external iliac artery of the ascending aorta with a ringed artificial vessel graft could not be visualized by hand injection of dye from the following day. that catheter (Fig. 6D). From these angiographic findThe surgery was performed under total cardiopulmoings, the patient’s aortic anatomy was postulated to be as nary bypass with pump perfusion from the left femoral shown in Figure 8A. artery combined with occlusion of the aorta by a Fogarty Fenestration of the dissecting intima was thought to be aortic occlusion balloon which was inserted from the necessary in order to save her right leg and kidney. A 7F ascending aorta into the true lumen of the aortic arch. Mullin’s dilator was advanced into the true lumen of the During surgery it was seen that the blood flow into the abdominal aorta with a 0.032-inch J guide wire from the false lumen through the fenestration was adequate. Five right femoral artery. Then a transseptal needle was in- months after percutaneous fenestration and the replaceserted into the dilator. Under the left anterior oblique flu- ment of the ascending aorta she remains in good condioroscopic view, the dissecting intima was easily punc- tion.
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Fig. 9. Puncture with a transseptal needle and Mullin’s dllator. (A) Puncture with a transseptal needle in the left anterlor oblique view. (B) Mullin’s dilator has been pushed into the false lumen. (C) Jgulde wire was inserted into the false lumen of the thoracic aorta. (D) Peripheral angioplasty balloon of 7 mm in diameter inflated to produce fenestration.
DISCUSSION The Need for Emergent Fenestration
Fig. 10. Case two. True lumen angiogram of the abdominal aorta with the catheter insemd through the right femoral artery after percutaneous fenestration provides good visualization of the rlght renal and external iliac arteries.
ing intima was the only possible treatment to save his life. In case two, replacement of the ascending aorta without fenestration might have induced the infarction of the right kidney, because the right renal artery had its origin from the false lumen which had only entry from but no reentry into the aorta. Thus, it is apparent that percutaneous fenestration was effective and inevitable in these two cases.
As mentioned earlier, the incidence of noncardiac vascular complications associated with aortic dissection has been reported to be as high as 33% [ 11. These complications are caused by obstruction of the blood flow into Method of Percutaneous Fenestration and the major aortic branches by the dissecting intima. Es- Possible Complications pecially in the acute phase of dissection, peripheral ischWhile spontaneous resolution of lower extremity ischemia such as in the lower extremities, kidneys, or intes- emia after catheter manipulation in the iliac artery or tines may cause serious problems for treatment [8]. In a abdominal aorta has been reported in two articles [6,7], series of 527 surgically treated cases of aortic dissection, only two cases of percutaneous fenestration for visceral 13% of patients with type I and 6% of those with type ischemia has been reported so far [9, lo]. These papers IIlb dissection had peripheral ischemia [5]. In another describe the penetration of the dissecting intima with the series of 325 cases of aortic dissection, 38 patients (12%) use of a guide wire and a guide catheter as late as 1 demonstrated some degree of lower extremity ischemia, month [9] or 27 months [lo] after acute aortic dissection. and one-third of these required a direct approach on the The present paper is the first to describe percutaneous abdominal aorta or iliofemoral segments to restore cir- fenestration with a transseptal needle during the acute culation [ l ] . In both of the patients described here, if phase of aortic dissection. The possible complications of emergency fenestration had not been performed, the percutaneous fenestration with a transseptal needle inright kidney might have been infarcted, and the lower clude perforation of the aortic wall, extension of dissecextremities might have become necrotic. Particularly in tion, and distal embolization. It can be thought that the case one, almost all surgical interventions were contrain- aortic wall puncture with such a needle as thin as a transdicated because of the history of aortic valve replacement septa1 one is relatively safe, because the frequency of and myocardial infarction and the presence of marked major complications associated with diagnostic transcardiomegaly. So, percutaneous fenestration of dissect- lumbar aortography has been reported to be only about
Fenestration for Aortic Dissection
135
3% [ll-131. A transseptal needle is thought to be supe- of choice in selected patients with visceral ischemia due rior to a guide wire for the puncture of a dissecting in- to acute aortic dissection. tima, because dye injection from the tip is possible only in the former. To avoid aortic wall perforation by a larger REFERENCES catheter, appropriate fluoroscopic views, which can be I . Cambria RP, Brewster DC, Gertler J , Moncure AC, Gusberg R, relatively easily obtained by aortography in multiple proTilson D, Darling RC, Hammond G , Megerman J , Abbott WM: jections, should be selected during needle puncture, and Vascular complications associated with spontaneous aortic dissection. J V a x Surg 7:199-209, 1988. dye injection should be done from the tip of the needle before the Mullin’s dilator is pushed into the opposite 2. Miller DC, Mitchell S, Oyerk PE, Stinson EB, Jamieson SW, Shumway N E Independent determinants of operative mortality lumen. It is thought not to be very important whether the for patients with aortic dissections. Circulation 70: 153-164, puncture is done from the true to the false or the false to 1984. the true lumen, because in case one the latter, and in case 3. Elefteriades JA, Hammond GL, Gusberg RJ. Kopf GS, Baldwin JC: Fenestration revisited: A safe and effective procedure for two the former occurred. The theoretical risks of distal descending aortic dissection. Arch Surg I25:786-79O, 1990. embolization or extension of the dissection cannot be 4. Schoon IM, Holm J, Sudow G: Lower-extremity ischemia in eliminated, but neither happened in our two cases, and aortic dissection: Report of three cases. Scand J Thor Cardiovasc even if they do, they are thought to be acceptable risks in Surg 19:93-95, 1985. such acute complicated settings, compared with the risks 5. DeBakey ME, McCollum CH. Crawford ES, Moms GCJ, Howell J, Noon GP. Lawne G: Dissection and dissecting aneurysms of of combined surgical aortic replacement and fenestrathe aorta: Twenty year follow-up of five hundred and twentytion.
Mechanism of the Restoration of Blood Flow to Lower Extremities In both of our patients, the puncture of the dissecting intima was done above the iliac bifurcation. If the window made by percutaneous fenestration allows blood to pass only into the occluded lumen, the blood flow to the lower extremities might not be restored. The reconstruction of the distal aorta and redirection of blood flow into the true lumen [3] as a result of the decompression of the false lumen after percutaneous fenestration are possible mechanisms for the restoration of blood flow to the lower extremities.
CONCLUSION
On the basis of the encouraging results observed in our patients, we suggest that percutaneous fenestration with a transseptal needle should be considered the treatment
seven patients treated surgically. Surgery 92:1118-1134, 1982. 6. Shumacker HB, lsch JH, Jolly WW: Stenotic and obstructive lesions in acute dissecting thoracic aortic aneurysms. Ann Surg 1811662-669, 1975. 7. Shah PM, Clauss RH. Dissecting hematoma presents as acute lower limb ischemia: Diagnostic patient profile and management. J Cardiovasc Surg 24:649-653, 1983. 8. DeBakey ME, Cooley DA, Creech 0: Surgical considerations of dissecting aneurysm of the aorta. Ann Surg 142586-612. 1955. 9. Williams DM, Brothers TE, Messina LM: Relief of mesenteric ischemia in type IIIc dissection with percutaneous fenestration of the aortic septum. Radiology 174:450-452, 1990. 10. Shimshak TM, Giorgi LV, Hartzler GO: Successful percutaneous transluminal angioplasty of an obstructed abdominal aorta secondary to a chronic dissection. Am J Cardiol61:486-487, 1988. 11. Bakal CW, Friedland RJ, Sprayregen S, Calligaro KD, Cynamon J . Veith FJ: Translumbar arch aortography: A retrospective controlled study of usefulness, technique, and safety. Radiology 178: 225-228, 1991. 12. Szilagyi DE, Smith RF, Elliot JPJ, Hageman JH: Translumbar aortography: A study of its safety and usefulness. Arch Surg 1121399-408, 1977. 13. Dorph S, Folke K: Complications in translumbar aortography: A comparion of direct needle puncture and aortic catheterization. Acta Radio1 12:750-756, 1973.
