Transaortic Septectomy as Treatment for Chronic Mesenteric Ischemia After Aortic Dissection

Abstract

Visceral ischemia can present as an acute or chronic complication of aortic dissection, which is associated with high morbidity and mortality rates, up to 50-87%. Furthermore, the optimal management strategy for this problem is unclear. The authors present a case of chronic mesenteric ischemia complicating a Stanford type A aortic dissection which was treated with transaortic septectomy.

A 56-year-old man presented with chronic abdominal pain and a 30-pound weight loss after operative repair of an ascending aortic dissection with replacement of his aortic valve and ascending aorta. Two prior attempts at balloon fenestration of his aortic dissection in the area of his mesenteric vessels had failed to improve his symptoms. Angiography, computed tomography scan, and duplex evaluation of the aorta revealed a 5 cm suprarenal aorta with the false lumen occupying the majority of the diameter. The origins of the mesenteric vessels from the true lumen were compressed by the septum. The patient underwent a septectomy and aortoplasty of his suprarenal aorta via a retroperitoneal approach. A postoperative duplex scan showed widely patent origins of the celiac, superior mesenteric, and renal arteries. The patient's postprandial pain completely resolved before hospital discharge.

Aortoplasty and septectomy presents a newly described treatment of complications of aortic dissection and has been utilized in the acute and chronic settings. It allows successful treatment of aneurysmal and occlusive complications in the dissected aorta. The evaluation and operative treatment of a patient with both these complications is discussed.

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References

1. Daily PO , Trueblood HW , Stinson EB , et al: Management of acute aortic dissections. Ann Thorac Surg 10:237-247, 1970.

2. DeBakey ME , McCollum CH , Crawford ES , et al: Dissection and dissecting aneurysms of the aorta: Twenty-year follow-up of 527 patients treated surgically. Surgery 92:1118-1134, 1982.

3. Cambria RP , Brewster DC , Gertler J , et al: Vascular complications associated with spontaneous aortic dissection. J Vasc Surg 7:199-209, 1988.

4. Cogbill TH , Gundersen AE , Travelli R : Mesenteric vascular insufficiency and claudication following acute dissecting thoracic aortic aneurysm. J Vasc Surg 2:472-476, 1985.

5. Slonim SM , Nyman U , Semba CP , et al: Aortic dissection: Percutaneous management of ischemic complications with endovascular stents and balloon fenestration. J Vasc Surg 23:241-251; discussion 251-253, 1996.

6. Williams DM , Brothers TE , Messina LM : Relief of mesenteric ischemia in type III aortic dissection with percutaneous fenestration of the aortic septum. Radiology 174:450-452, 1990.

7. Crawford ES : The diagnosis and management of aortic dissection. JAMA 264:2537-2541, 1990.

8. Walker PJ , Dake MD , Mitchell RS , et al: The use of endovascular techniques for the treatment of complications of aortic dissection. J Vasc Surg 18:1042-1051, 1993.

9. Saito S , Arai H , Kim K , et al: Percutaneous fenestration of dissecting intima with a transseptal needle. A new therapeutic technique for visceral ischemia complicating acute aortic dissection. Cathet Cardiovasc Diagn 26:130-135, 1992.

10.

10. Williams GM : Treatment of chronic expanding dissecting aneurysms of the descending thoracic and upper abdominal aorta by extended aortotomy, removal of the dissected intima, and closure. J Vasc Surg 18:441-448; discussion 448-449, 1993.

11.

11. Webb TH , Williams GM : Abdominal aortic tailoring for renal, visceral, and lower extremity malperfusion resulting from acute aortic dissection. J Vasc Surg 26:474-480; discussion 480-481, 1997.