References: 1- Ho AF, Chua TW, Seth P et al. Atypical presentation of traumatic aortic injury. Case Rep Emerg Med. 2014;2014:864301. 2- Riesenman PJ, Brooks JD, Farber MA. Acute blunt traumatic injury to the descending thoracic aorta. J Vasc Surg. 2012 Nov;56(5):1274-80. 3- Di Eusanio M, Folesani G, Berretta P et al. Delayed management of blunt traumatic aortic injury: open surgical versus endovascular repair. Ann Thorac Surg. 2013 May;95(5):1591-7.

 

Hybrid procedure for an atypical lesion of the thoracic aorta Gabriel Verdon1, Jean-Marc Corpataux1, Francois Saucy1

Introduction: We report the case of a patient treated by a thoracic endograft for a complicated type B dissection of the descending aorta. On the diagnostic angio CT-scan, the lesion appeared atypical and the etiology remained unclear. An emergency hybrid intervention was performed successfully with the transposition of the left subclavian artery on the left common carotid artery and the endovascular procedure.

Figure A Figure B

Methods: A 76-year-old male patient, known for treated hypertension and a cardiac catheter ablation using radiofrequency for auricular fibrillation performed the last month, was transfered to our clinic for important chest pains and diaphoresis. The angio CT-scan showed a focal aortic lesion at the level of the left subclavian artery, associated with an hemomediastinum (figure A, B). The differential diagnosis included penetrating aortic ulcer with intramural hematoma and a complicated type B dissection. The patient was managed urgently by an hybrid approach. Firstly, we transposed the left subclavian artery on the left common carotid artery, including subclavian and vertebral artery ligation and reconstruction with an end-to-side anastomosis without bypass. Then through a bilateral femoral approach, we implanted a comformable Gore TAG® thoracic endoprosthesis (Gore, Newark, New Jersey). The ostium of the left subclavian artery was covered successfully and the brachiocephalic trunk and the left common carotid remained patent. Neuromonitoring in the form of somatosensory-evoked potentials provided excellent results.

Results: The final angiogram confirmed a successfully procedure with complete coverage and exclusion of the dissection by the thoracic endograft (figure C). The follow-up CT scan (figure D) showed no endoleaks or migration of the endoprosthesis and all supraaortic vessels remained patent, included the reconstruction of the left subclavian artery. The patient had a smooth recovery without any complications of left arm or spinal cord ischemia or stroke.

Figure C Figure D

Conclusion: This case describes the successfully management of an atypical complicated aortic type B dissection using an hybrid procedure.