Antegrade Intravascular Ultrasound (IVUS) Examination in Acute Type A Aortic Dissection
Rana O. Afifi, MD, Akiko Tanaka, MD, Harleen K. Sandhu, MD, MPH, Charles C. Miller, III, PhD, Wande B. Pratt, MD, Kristofer M. Charlton-Ouw, MD, Naveed U. Saqib, MD, Hazim J. Safi, MD, Anthony L. Estrera, MD.
The University of Texas Health Science Center at Houston, Houston, TX, USA.
OBJECTIVES: Mesenteric malperfusion is a devastating complication of acute type A aortic dissection (ATAD), with a high mortality rate. Our experience has demonstrated that central aortic repair usually resolves peripheral ischemia, but in few of the cases, an additional intervention is required. Intravascular ultrasound (IVUS), when performed, can provide useful information regarding intimal tear location and branch vessel involvement. We present a case series of patients with ATAD, who underwent antegrade IVUS examination via the ascending aortic graft METHODS: We reviewed all cases of ATAD from 2011 to 2016, and identified patients who underwent urgent open repair of ascending aorta. IVUS examination was performed in cases where visceral (mesenteric or renal) ischemia was suspected - either clinically or radiographically. The mid-portion or the side arm of the ascending aortic Dacron graft was punctured with an 8-French sheath in an antegrade fashion prior to chest wall closure. The ultrasound probe was advanced into the descending and abdominal aorta. Reexpansion of the true lumen, patency of branch vessels, and the presence of additional intimal tears was determined. Baseline characteristics, intraoperative findings, and postoperative outcomes were evaluated. RESULTS: Between January 2011 and July 2016, we performed 203 open ascending aortic repairs for ATAD. In nine patients, IVUS was performed, with 100% technical success. True lumen expansion was noted in all 9 patients. One patient subsequently developed mesenteric ischemia 24 hours following aortic repair, and required laparotomy and bowel resection. The remaining 8 patients recovered and were discharged home without further intervention CONCLUSIONS: Utilization of IVUS in the treatment of aortic dissection is increasing in the recent years. Our series demonstrates the feasibility and safety of an antegrade approach through the Dacron graft. As sonographic technology evolves, further studies are needed to evaluate the role of IVUS in early detection of visceral ischemia and decision-making during surgery.
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