In November 1998, a 29-year-old man was admitted to another hospital with sudden onset of epigastric pain that suggested an acute abdominal problem. Because an echocardiogram raised the suspicion of acute dissection of the abdominal aorta, the patient was referred to our unit for further evaluation.
On admission, he denied any history of heart disease, reporting only a recent diagnosis of hypertension. His blood pressure was 150/80 mmHg and his pulse rate was 65 beats/min; radial pulses were present and symmetrical, while femoral pulses were reduced. Chest radiography showed a widened superior mediastinum, and electrocardiography showed sinus bradycardia with left ventricular hypertrophy. A transthoracic 2-dimensional echocardiogram revealed a flap in the descending thoracic aorta. Both computed tomographic (CT) scanning (Fig. 1) and nuclear magnetic resonance imaging (MRI) confirmed the presence of a type-B dissection starting just below the origin of the left subclavian artery; the MRI also suggested the presence of an isthmic coarctation (Fig. 2).
Fig. 1 Preoperative computed tomographic scan shows dissection of the descending aorta.
Fig. 2 Preoperative nuclear magnetic resonance imaging shows the type-B aortic dissection starting just below the left subclavian artery. Arrowhead indicates the site of isthmic coarctation.
At first, the patient was treated medically. Despite control of his hypertension, the persistence of interscapular pain was considered an indication for surgical repair.
Through a posterolateral thoracotomy, we observed marked dilatation of the descending aorta, with evidence of a subadventitial hematoma that involved the distal aortic arch and extended below the diaphragm. Adequate control of the aortic arch appeared impossible through this approach, for the lesion appeared to require correction under deep hypothermic circulatory arrest. Moreover, perfusion through the femoral vessels appeared to be hazardous, so we performed a median sternotomy with cannulation of the ascending aorta and both venae cavae. Cardiopulmonary bypass was discontinued at a rectal temperature of 20 °C, and retrograde cerebral perfusion was started through the superior vena cava. The thoracic aorta was opened, revealing the intimal tear and a tight aortic coarctation. During 20 minutes of circulatory arrest, we repaired the lesion by interposing a 26-mm vascular graft and by reinforcing the sutures with gelatin resorcin glue and Teflon strips. One year after surgery, the patient was asymptomatic, and a follow-up CT scan showed thrombosis of the false lumen without evidence of further aortic dilatation.
Acute aortic dissection distal to isthmic coarctation is extremely rare and has been reported, to our knowledge, in only 3 other cases. 1–3
Footnotes
Address for reprints: U. Bortolotti, MD, U.O. Cardiochirurgia, Ospedale Cisanello, Via Paradisa 2, 56124 Pisa, Italy
References
- 1.Kreitmann P, Schmitt R, Jourdan J, Bourlon F, Sabatier M, Pratte B, Dor V. Aneurysms complicating coarctation of the aorta: anatomic aspects and evolution. Report of six successful surgical cases. Thorac Cardiovasc Surg 1982;30:315–8. [DOI] [PubMed]
- 2.Graeter T, Schaefer C, Prokop M, Laas J. Three-dimensional vascular imaging—an additional diagnostic tool. Thorac Cardiovasc Surg 1993;41:183–5. [DOI] [PubMed]
- 3.Yamaguchi A, Adachi H, Kamio H, Murata S, Okada M, Adachi K, et al. A combination of preductal aortic coarctation and type B dissection: report of a case. Surg Today 1998;28:435–7. [DOI] [PubMed]