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Conservative Management Of Iatrogenic Type A Aortic Dissection From Endovascular Carotid Intervention
Claire J. Yang, MD, Anthony Chau, MD, Nii-Kabu Kabutey, MD.
UC Irvine, Orange, CA, USA.
DEMOGRAPHICS: 79-year-old male with a history of coronary artery disease, hypertension, hyperlipidemia, diabetes, and ocular ischemic syndrome.
HISTORY: The patient was found to have bilateral carotid artery stenosis, with high-grade stenosis of left greater than right proximal internal carotid artery as well as left common carotid artery (CCA) origin. After multidisciplinary case, consensus was for staged surgical approach with right carotid endarterectomy (CEA) first followed by left CEA and CCA stenting. Right CEA was uneventful.
PLAN: We planned to perform carotid cutdown followed by retrograde CCA puncture, place proximal CCA stent, and perform CEA. Initial angiogram after retrograde CCA access raised concern for dissection into aortic arch. Multiple attempts at crossing the stenosis were unsuccessful. We then proceeded with the CEA and attempted to cross the lesion from femoral artery access, also unsuccessfully. Given concern for inadequate carotid inflow and the retrograde aortic dissection, we decided to perform a subclavian-carotid bypass and interval ligation of the left CCA. Postoperative CTA showed a large type A aortic dissection extending to the aortic root without contrast filling the false lumen. Because of the mechanism of dissection and the ligation of the CCA limiting flow, we elected to pursue conservative management. CTA 12 hours later showed significant improvement.
DISCUSSION: Iatrogenic type A aortic dissection is an uncommon complication following endovascular procedures involving the aortic arch. There are a handful of case reports describing conservative management of these dissections which usually occur in the setting of coronary catheterization. While typically acute type A aortic dissection would warrant urgent involvement by cardiothoracic surgery, in this case several factors led us to pursue conservative management. Since the entry tear was likely in the proximal CCA, ligation of the CCA should limit further flow and prevent propagating the dissection. This was confirmed by lack of contrast in the false lumen on the CTA. Additionally, the patient remained asymptomatic and was able to maintain adequate blood pressure control. This case report suggests that for iatrogenic type A aortic dissection conservative management can be successful in select patients.
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