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COMPLICATED TYPE B AORTIC DISSECTION IN THE THIRD TRIMESTER OF PREGNANCY
Oonagh Scallan, Barbra de Vrijer, Audra Duncan.
Western University, London, ON, Canada.
DEMOGRAPHICS: A healthy 38-year-old primigravida with a family history of Marfan syndrome (MFS) presenting with severe chest and back pain at 35 weeks gestation.
HISTORY: On examination, she was neurologically intact, had mild abdominal tenderness, and palpable pedal pulses with no lower extremity ischemia. Computed tomographic angiography (CTA) demonstrated a type B4,10 aortic dissection (TBAD). The aortic root was dilated to 41mm. The descending thoracic aorta measured 40mm.The celiac, SMA, and right renal arteries arose from the compressed true lumen. (Figure 1). She was admitted to the ICU for blood pressure control and fetal monitoring. In the following 6 hours, she developed abdominal pain with an elevated lactate at 4.7 mmol/L, concerning for visceral malperfusion.
PLAN: The patient was brought urgently to the operating room and first underwent C-section through a lower midline laparotomy. A healthy preterm fetus was delivered. The laparotomy was extended proximally to reveal diffuse hypoperfusion of the small bowel without full-thickness infarction. A retrograde SMA bypass was performed with a 7mm Dacron graft. The small bowel perfusion improved. A 360° omental wrap was used to cover the graft. The gallbladder appeared ischemic necessitating cholecystectomy. The patient recovered with no complications and was discharged on postoperative day 14 with oral antihypertensives. Genetic testing confirmed FBN1 gene mutation. Follow up CTA at 9 months demonstrates a stable TBAD and patent SMA bypass. The infant is a healthy and developmentally normal female who is also positive for FBN1 gene mutation.
DISCUSSION: Aortic dissection in pregnancy is rare and often associated with connective tissue disorders. Most occur in the third trimester or postpartum, when hemodynamic shifts are greatest, which is also a time when it is safest for pregnant patients to undergo anesthesia. TEVAR for complicated TBAD in patients with MFS carries a risk of retrograde type A aortic dissection and high mortality, especially in patients with a dilated thoracic aorta or aortic root like this patient. In this case, management of the malperfusion with direct revascularization of the SMA to prevent catastrophic bowel ischemia was felt to be lower risk and more expeditious than proximal aortic TEVAR.
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