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Iatrogenic Aortic Coarctation After Elephant Trunk For Acute Type A Aortic Dissection
Emidio Germano, MD, Animesh Rathore, MD, David Dexter, MD.
Eastern Virginia Medical School, Norfolk, VA, USA.
OBJECTIVES: To present a case of iatrogenic aortic coarctation post-elephant trunk (ET) procedure for type A aortic dissection. The use of TEVAR to expand collapsed ET graft has not been described.
METHODS: Case report of a 40-year-old male with a medical history of hypertension and cigarette smoking who presented with acute onset of dizziness, hypotension, acute kidney injury (AKI) (Cr 1.4, baseline 0.9) and type 2 myocardial infarction. Echocardiogram showed severe aortic insufficiency, and CTA evidenced an acute type A0-3 aortic dissection, with circumferential multi-luminal dissection flap at aortic arch involving all brachiocephalic vessels and an aneurysmal proximal descending thoracic aorta (38mm).
RESULTS: Emergent Bentall procedure with total arch replacement using a 24mm 4-branched aortic graft in a traditional elephant trunk (ET) fashion was performed. Postoperatively, progressively worsening AKI (peak Cr 3.0), shock liver (peak AST 863, ALT 491, T. bili 0.6) and lower extremity ischemia were noted, with monophasic waveforms detected on renal and mesenteric duplex, triggering vascular surgery consultation. On postoperative day 2, repeat CTA showed ET collapse causing an aortic coarctation physiology. Urgent zone 3-4 thoracic endovascular aneurysm repair (TEVAR) with Gore TAG 31mm x 150mm was performed using single right common femoral access, followed by balloon angioplasty using a 16mm x 34mm Gore Tri-Lobe balloon at proximal seal zone. Post-deployment angiogram showed successful ET graft expansion (
Figure). On the third day post-TEVAR, paraplegia was evidenced upon sedation wean following chest closure. Stroke work-up was negative and spinal cord ischemia protocol was initiated, with gradual improvement noted on the next day leading to complete neurological recovery after 6 days. Additionally, renal and hepatic functions normalized on day 4. The patient was discharged on hospital day 22 with predischarge CTA showing excellent aortic remodeling.
CONCLUSIONS: Aortic coarctation is a rare complication following ET procedure, thus high index of suspicion is required to differentiate it with other etiologies of postoperative malperfusion.
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