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Type I Aortic Dissection with Mid Body Ischemia
Megan Lenihan, Kendal M. Endicott
Inova Health Systems, Falls Church, VA
BACKGROUND - The treatment of mesenteric malperfusion syndrome in the setting of a Type I aortic dissections has been studied extensively with varying institutional approaches. The treatment algorithm in the setting of lower extremity and pelvic malperfusion has been less well defined.
METHODS - A 30-year-old female presented to an outside hospital with acute onset lower extremity paralysis, bladder incontinence, and chest pain. Imaging demonstrated a Type I aortic dissection with aneurysmal aortic root, effaced true lumen (TL) across the visceral segment, and thrombosis of the infrarenal aorta with flow reconstituting in the bilateral external iliac arteries. Six hours after the index presentation, she was evaluated at our institution. The patient remained hemodynamically stable on IV anti-impulse control. Femoral through pedal pulses were absent with dense paralysis of the lower extremities including loss of hip flexion. She also demonstrated mottling from the waist down with a lactate of 8.3.
RESULTS - After multidisciplinary discussion, decision was made to defer central repair in favor of first re-perfusing the pelvis and lower extremities. In the operating room, bilateral percutaneous femoral access was obtained. Intravascular ultrasound demonstrated thrombosis of the false lumen (FL) in the infrarenal aorta with collapse of the TL during diastole in zone 5 and across the visceral segment. After confirming TL placement of both wires, a Zenith Dissection Endovascular Stent (ZDES, Cook Medical) was placed from zone 3 to the aortic bifurcation (Figure 1). Subsequent imaging demonstrated restored perfusion (Figure 2,3). Bilateral four compartment fasciotomies were performed with return of bilateral pedal signals. The patient was admitted to the ICU for resuscitation. Lactate cleared with CVVH initiated for treatment of rhabdomyolysis. Patient demonstrated movement in her bilateral lower extremities. Seventy-two hours following presentation, she was taken for ascending repair. Post-operatively, she recovered full lower extremity function with palpable pulses and improvement in renal function.
CONCLUSIONS - We present a case of Type I dissection who presented with midbody ischemia treated first with a ZDES stent to restore lower extremity perfusion. Similar to mesenteric malperfusion, Type I aortic dissections with profound midbody ischemia may benefit from deferred central repair.
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