TRANSAPICAL ACCESS — A COMPLEMENTARY ACCESS FOR TEVAR IN A STANFORD TYPE A DISSECTION

Authors

  • Inês Antunes Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar do Porto, Hospital de Santo António
  • Rui Machado Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar do Porto, Hospital de Santo António; Instituto de Ciências Biomédicas Abel Salazar
  • Luís Loureiro Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar do Porto, Hospital de Santo António
  • Carlos Pereira Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar do Porto, Hospital de Santo António
  • Duarte Rego Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar do Porto, Hospital de Santo António
  • Vitor Ferreira Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar do Porto, Hospital de Santo António
  • João Gonçalves Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar do Porto, Hospital de Santo António
  • Gabriela Teixeira Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar do Porto, Hospital de Santo António
  • Carlos Veiga Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar do Porto, Hospital de Santo António
  • Daniel Mendes Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar do Porto, Hospital de Santo António
  • Rui de Almeida Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar do Porto, Hospital de Santo António

DOI:

https://doi.org/10.48750/acv.189

Keywords:

Transapical access, endovascular treatment, type A aortic dissection

Abstract

Introduction/Objectives: Type A aortic dissection (AD) usually requires urgent surgical treatment and aortic segment replacement remains the gold standard. However, it is a very aggressive procedure and some patients are considered too frail for this treatment. Nowadays, endovascular repair represents an alternative treatment but still without precise indications. Our objective is to present a case of hybrid treatment of a type A AD with resource a transapical cardiac access.

Material/Methods: Clinical case and literature review.

Results: A 65-year-old man with history of chronic pulmonary obstructive disease, atrial fibrillation and hypertension came to the emergency department with abdominal pain. He underwent angio-CT that revealed type A AD with an PAU in the ascending aorta (AA). After evaluation by cardiac surgery, he was considered too frail for conventional surgery. Angio-CT was repeated after two weeks of medical treatment and revealed false aneurysm growth, with imminent risk of rupture. We thought about endovascular treatment and different options were considered, the final decision was to propose the patient for an hybrid treatment. The procedure was started with a femoro-rigth axilar bypass and embolization of the brachyocephalic trunk. Then an endoprosthesis (Valiant®) was delivered below the left subclavian artery and two periscopes (Viabahn®) were progressed form left carotid and axillar arteries and the second endoprosthesis (Valiant®) was released into the aorta, inside the first, with coverage of the left common carotid and subclavian, and the Viabahn® were released. After multiple attempts, it was not possible to progress the third endoprosthesis AA because of lack of support and hemodynamic instability whenever the guidewire was progressed for the left ventricle and the procedure was interrupted. Subsequently performed angio-CT revealed permeable AA dissection and untreated false aneurysm. We discussed other options and an anterograde (transapical) approach was considered to progress a guidewire on through-and-through to achieve the support we need to progress the endoprothesis. With the support of the cardiac surgery the cardiac apex was punctured and using the through-and-through technique the guide wire was progressed to femoral artery which allowed advancement of the endoprosthesis (Valiant®) through the retrograde pathway and release under rapid-pacing in the AA with good final result.

Discussion/Conclusions: Endovascular treatment is an alternative in patients of high clinical risk and adequate anatomical characteristics, yet technically challenging. When the retrograde progression of the endoprosthesis is not achieved, the transapical cardiac approach is an alternative to be considered.

Downloads

Download data is not yet available.

References

1. Trimarchi S, Nienaber CA, Rampoldi V, Myrmel T, Suzuki T, Mehta
RH, et al. Contemporary results of surgery in acute type A aortic
dissection: The International Registry of Acute Aortic Dissection
experience. The Journal of Thoracic and Carsiovascular
Surgery,2005:112–122
2. Grabenwoger M, Weiss G. Type A aortic dissection: the extent
of surgical intervention. Annals of Cardiothoracic Surgery;
2013;2(2):212–215
3. Senay S, Alhan C, Toraman F, Karabulut H, Dagdelen S and Cagil
H. Endovascular Stent-graft Treatment of Type A Dissection:
Case Report and Review of Literature. Eur J Vasc Endovasc
Surg.2007,34:457–460
4. Grenon SM, MacDonald S, Sidhu RS, Reid JD, Cheung A, Hsiang Y et
al. Successful ventricular transapical thoracic endovascular graft
deployment in a pig model. J Vasc Surg,2008;48(5):1301–1305
5. Enrico Ferrari. Apical access and closure devices for transapical
transcatheter heart valve procedures. Swiss Med Wkly.
2016;146:w141237.
6. Cribier A. Development of transcatheter aortic valve implantation
(TAVI): a 20-year odyssey. Arch Cardiovasc Dis,2012;105(3):146–152
7. Shults C, Gunter R, Thourani V. The versatility of transapical
access: Will it lead to a completely new approach to valvular
therapy? Ann Cardiothorac Surg.2012;1(2):220–223
8. Ramponi F, Stephen MS, Wilson MK, Valley MP. Think differently:
trans-apical platform for TEVAR. Ann Cardiothorac
Surg,2012:1(3):412–416

Downloads

Published

2017-09-30

How to Cite

1.
Antunes I, Machado R, Loureiro L, Pereira C, Rego D, Ferreira V, Gonçalves J, Teixeira G, Veiga C, Mendes D, de Almeida R. TRANSAPICAL ACCESS — A COMPLEMENTARY ACCESS FOR TEVAR IN A STANFORD TYPE A DISSECTION. Angiol Cir Vasc [Internet]. 2017 Sep. 30 [cited 2024 Mar. 29];13(3):36-40. Available from: https://acvjournal.com/index.php/acv/article/view/189

Issue

Section

Clinical Case

Similar Articles

You may also start an advanced similarity search for this article.