Intraoperative aortic dissection

Intraoperative iatrogenic type B aortic dissection. Temporary perfusion pause, immediate restoration and final solution

We present the case of a 74-year-old female patient with a 50 mm ascending aortic aneurysm who underwent ascending aorta replacement. During routine open heart surgery, suboptimal flow in the cardiopulmonary bypass circuit, led to the discovery of a type B aortic dissection with substantial flow in the false lumen. Conservative management was chosen, focusing on blood pressure control in the ICU. Despite an initial uneventful recovery the patient developed malperfusion syndrome prompting consideration of endovascular repair. Following a temporary improvement, malperfusion symptoms recurred, leading to a successful endovascular repair, with complete thrombosis of the false lumen.

Intraoperative Type B Aortic Dissection With Malperfusion in a Patient With Marfan Syndrome

We present the case of a 72-year-old man diagnosed with an aortic root aneurysm who was then diagnosed with Marfan syndrome. The patient suffered an intraoperative type B dissection with lower extremity malperfusion managed with an axillary-bifemoral extra-anatomic bypass.

Use of intraoperative transesophageal echocardiography and epiaortic ultrasound to diagnose false lumen enlargement of chronic aortic dissection

In communicating aortic dissection, if only the entry or reentry is closed, residual blood flow may cause enlargement of the false lumen. In this case, surgeons were unable to occlude the entry with a stent graft due to the strong flexion of the bilateral common iliac arteries, so they closed only the reentry in the hope that blood flow from the reentry would be high. Unfortunately, due to the high blood flow from the entry, the false lumen was enlarged. But the use of transesophageal echocardiography and epiaortic ultrasound contributed to its diagnosis.

Cardiopulmonary Bypass Emergencies and Intraoperative Issues

Cardiopulmonary bypass (CPB) is a complex biomechanical engineering undertaking and an essential component of cardiac surgery. However, similar to all complex bioengineering systems, CPB activities are prone to a variety of safety and biomechanical issues. In this narrative review article, the authors discuss the preventative and intraoperative management strategies for a number of intraoperative CPB emergencies, including cannulation complications (dissection, malposition, gas embolism), CPB equipment issues (heater-cooler failure, oxygenator issues, electrical failure, and tubing rupture), CPB circuit thrombosis, medication issues, awareness during CPB, and CPB issues during transcatheter aortic valve replacement.

Patching an aortic tear using the side-arm and surrounding skirt of a physician-modified ascending aortic graft

BACKGROUND AND AIM OF STUDY

Aortic complications during cannulation must be managed urgently and often require hypothermic circulatory arrest. We report a unique management strategy to repair an aortic tear without dissection by modifying a Dacron ascending aortic graft with side-arm.

CASE PRESENTATION

A 32-year-old female patient undergoing reoperative cardiac surgery suffered an unexpected aortic tear during cannulation for cardiopulmonary bypass. The tear was repaired by utilizing a physician-modified ascending aortic graft with side-arm, in which the surrounding skirt of the side-arm was cut from the circumferential graft to patch the defect. The patient was rewarmed with the side-arm serving as arterial inflow for the bypass circuit, and the remainder of the operation proceeded without complication.

CONCLUSION

This type of aortic repair for aortic tears without dissection can offer the patient the benefit of avoiding multiple aortotomies in a weakened aorta, reducing circulatory arrest time, and re-establishing a central cannulation strategy for cardiopulmonary bypass.

Immediate Recognition and Surgical Treatment of Iatrogenic Acute Type A Aortic Dissection Is Associated with Low Hospital Mortality and High Intermediate-Term Survival

Background

To investigate short- and intermediate-term outcomes of immediate (on table) recognition and surgical treatment of iatrogenic acute type A aortic dissection (ATAD) that occurred during the course of the cardiac surgical procedures.

Methods

Of 23,143 adult patients undergoing cardiac surgical procedures at our institution from January 2016 to December 2020, 21 (0.09%) suffered from intraoperative iatrogenic ATAD and underwent immediate aortic repair. Their clinical characteristics, in-hospital outcomes and follow-up results were analyzed.

Results

Among the 21 patients, 13 (61.9%) suffered from hypertension, and 14 (66.7%) had a dilated ascending aorta. In-hospital mortality was 9.5%, and new onset of permanent neurologic deficit was recorded in one patient. During a median follow-up of 36.0 months, all 18 follow-up patients survived without repeated surgeries. A follow-up computed tomography (CT) examination revealed a residual false lumen in the aortic arch in 3 patients and in the descending aorta in 8, with residual false lumen perfusion in one.

Conclusions

Immediate recognition and surgical repair of ATAD that developed as a complication during cardiac surgical procedures are associated with low mortality and high intermediate-term survival.

The Epiaortic Ultrasound Diagnosis of Iatrogenic Subadventitial Hematoma

Iatrogenic aortic injury is a rare but potentially lethal complication of cardiac surgery. While sometimes resulting in aortic dissection or intramural hematoma, injury more frequently results in subadventitial hematoma, a more benign pathology. Here, we describe a case where intraoperative transesophageal echocardiography (TEE) identified such a hematoma but was unable to rule out dissection. Epiaortic ultrasound was subsequently performed, which definitively demonstrated the absence of a dissection flap or extraluminal flow. Per our review, this is the first report documenting the successful use of epiaortic imaging to identify subadventitial hematoma in the setting of inconclusive TEE findings.

Diagnostic challenges with transesophageal echocardiography for intraoperative iatrogenic aortic dissection: Role of epiaortic ultrasound

Iatrogenic aortic dissection is a rare and serious complication of cardiac surgery with an incidence between 0.12% and 0.16%. Dissections involving an intimal flap can be detected using trans-esophageal echocardiography (TEE) with a sensitivity of 94%–100% and specificity of 77%–100%. Rarely, dissections can occur that are not detectable by TEE. There have been reports of iatrogenic dissection in the ascending aortic cannulation site; however, a dissection at the antegrade cardioplegia cannulation site is very rare. It also presents challenges associated with early diagnosis and appropriate intervention. We are describing a rare case of aortic dissection at the antegrade cardioplegia cannulation site in the proximal ascending aorta. The dissection was unable to be visualized with TEE initially, and required epi-aortic ultrasound to diagnose dissection in timely manner.

Iatrogenic Aortic Dissection Associated With Cardiac Surgery: A Narrative Review

Iatrogenic aortic dissection (iAD) is a relatively rare but a life-threatening complication associated with cardiac surgery. All members of the team caring for cardiac surgical patients (surgeons, perfusionists, and anesthesiologists) must be familiar with this complication to minimize its incidence and improve outcome. The present narrative review focuses on iAD occurring intraoperatively and during the early postoperative period (within 1 month) of cardiac surgery. The review also addresses iAD that occurs late (beyond 1 month) after cardiac surgery and iAD associated with other procedures. iAD occurs in about 0.06% of cases when the ascending aorta is the site of arterial cannulation, in about 0.6% when the femoral or iliac arteries are used, and in about 0.5% when the axillary or subclavian arteries are used. Mortality is estimated to be 30% but is more than double if not recognized until the postoperative period. Site of origin of dissection is most commonly the arterial inflow cannula (∼33%). Other common sites are the aortic cross-clamp or partial occlusion clamp (∼29%) and the proximal saphenous vein anastomosis site (14%). Sixty percent of cases occur during coronary artery bypass graft (CABG) surgery and 17% during aortic valve surgery with or without CABG. iAD may be somewhat less common in off-pump versus on-pump CABG but is still not very rare. Risk factors, presentation, diagnosis, and management are reviewed in detail as is the key role of the use of echocardiography in the early diagnosis of iAD and for guiding its management.

Iatrogenic dissection of the descending aorta: Conservative or endovascular treatment?

Transcatheter aortic valve implantation (TAVI) is without any doubt a standard technique and the treatment of choice of severe aortic valve stenosis (AVS) in very high-operative risk patients. However, a number of complications may occur and has been described. Improper valve position, valve migration, paravalvular regurgitation, conduction disturbances, stroke and aortic dissection have been succeeded despite the perfection of the technique. For anyone of the complications above described, a solution may be invented. We present an interesting case of an 81-year-old woman with severe AVS treated through TAVI due to very high operative risk. This female, 12 days later presented with thoracic pain and shortness of breath and through the computed tomography of the chest performed was diagnosed a dissection of the descending aorta. She successfully underwent on thoracic endovascular aortic repair. In this report, we refer the bibliographic data and we discuss the treatment options in these cases.

Iatrogenic aortic dissection after minimally invasive aortic valve replacement: a case report

BACKGROUND

As minimally invasive cardiac and vascular procedures are on the rise, the incidence of iatrogenic acute aortic dissection (IAAD) will increase. Cardiovascular professionals should be aware about the risk factors, means of prevention and best management options for IAAD in the perioperative setting.

CASE PRESENTATION

We present the successful clinical management of a complicated case of IAAD after minimally invasive aortic valve replacement.

CONCLUSION

High index of suspicion is required for prompt diagnosis of IAAD; collaboration of the whole perioperative team is imperative for management of this catastrophe.