Mesenteric vascular insufficiency and claudication following acute dissecting thoracic aortic aneurysm

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1 Mesenteric vascular insufficiency and claudication following acute dissecting thoracic aortic aneurysm Thomas H. Cogbill, M.D., A. Erik Gundersen, M.D., and Renato TraveUi, M.D., La Crosse, Wisc. Mesenteric vascular insufficiency and claudication of the left leg were observed in a patient 6 weeks after intraluminal aortic prosthesis placement for acute type III thoracic aortic dissection. Aortography revealed double-channel deformity of the thoracoabdominal aorta and complete occlusion of the celiac axis, inferior mesenteric artery, and left common iliac artery. An aortobi-iliac interposition graft placed end to end with an additional limb to the common hepatic artery was curative. (J VASC SURG 1985; 2:472-6.) The surgical management of acute dissecting thoracic aortic aneurysms has been detailed in several recent comprehensive reports. 1,2 However, there has been very little documentation of the late stenotic and obstructive lesions of major aortic branches secondary to aortic dissection. Even less has been written about the operative management of these lesions. We report a case illustrating successful surgical treatment of late mesentetic vascular insufficiency and claudication following type III thoracic aortic dissection. CASE REPORT A 67-year-old man with a 4-year history of well-differentiated lymphocytic lymphoma was admitted to the La Crosse Lutheran Hospital with severe chest and back pain of several hours' duration. Findings at physical examination demonstrated hypertension. Chest x-ray films revealed widening of the aortic shadow and aortography confirmed the diagnosis of thoracic aortic dissection at the origin of the left subclavian artery. Chest and back pain subsided as antihypertensive agents were administered until the patient's sixth day in the hospital when pain recurred in association with abdominal pain, leg cramps, and oliguria. The patient was transported to the operating room and an intraluminal aortic prosthesis was placcd distal to the left subclavian artery after reapproximation of the dissected layers. Restoration of the right femoral pulse and urine output immediately followed the procedure. The left leg was warm but no left femoral pulse was palpable. The From the Departments of Vascular Surgery (Dr. Cogbill), Cardiothoracic Surgery (Dr. Gundersen), and Radiology (Dr. Travelli), Gundersen Clinic/La Crosse Lutheran Hospital and the Wisconsin Heart Institute. Reprint requests: Thomas H. CogbiU, M.D., Department of Surgery, Gundersen Clinic, 1836 South Ave., La Crosse, WI patient recovered uneventfully and was discharged on the twentieth day after surgery. Six weeks after placement of the intraluminal aortic prosthesis, the patient was readmitted for evaluation of severe intermittent abdominal pain and daudication of the left leg. Abdominal pain occurred 30 to 60 minutes after every meal and lasted 1 to 3 hours. Pain was associated with diaphoresis and severe nausea. Findings at physical examination were normal except for the absence of the left femoral pulse. Results of an upper gastrointestinal series and barium enema were normal. Segmental limb Doppler pressures predicted left iliac artery occlusion. Thoracoabdominal aortography demonstrated a double-channel deformity of the descending aorta (Fig. 1). The false channel comprised the majority of the lumen below the renal arteries. Patency of the superior mesenteric artery from a markedly tapered true lumen was demonstrated. The celiac axis origin was not visualized and celiac axis vessels filled slowly in a retrograde fashion from the s~> perior mesenteric artery (Figs. 2 and 3). The left rer~al artery filled from the false channel and the right from the truc lumen. The left common iliac origin was totally occluded and the right common iliac artery filled from the false channel. The inferior mescnteric artery was not visualized (Fig. 4). Disabling intestinal angina continued as preoperative parenteral nutrition was administered for 5 days. At abdominal exploration, aortobi-iliac reconstruction was performed with a mm woven bifurcated Dacron graft. All anastomoses were performed end to end. The proximal anastomosis was sutured to the false channel below the renal arteries with Teflon pledget reinforcement. A 6 mm woven Dacron straight graft was then placed from the bifurcated graft to the common hepatic artery (Fig. 5). The inferior mesentcric artery had been obliterated and the superior mesenteric artery maintained a strong palpable pulse. The postoperative course was complicated by hyper- 472

2 Volume2 Number 3 May 1985 l/lesenteric insufficiency after dissecting aortic aneurysm 473 Fig. 1. Thoracic aortogram demonstrating intraluminal aortic prosthesis (black arrow) within true lumen and adjacent false channel distally (white arrow). Fig. 3. Lateral abdominal aortogram demonstrates filling of superior mesenteric artery (SMA) and right renal artery from true ktmen of aorta. Origin of celiac axis is completely obliterated (arrow). intestinal angina and complete resolution of claudication of the lower extremity. An intravenous digital subtraction aortogram was performed 16 months after reconstruction and confirmed patency of all graft limbs (Fig. 6). The patient has returned to part-time employment and lymphoma remains in remission. Fig. 2. Postcroanterior view of upper abdominal aortogram delineating filling of superior mesenteric artery and right renal artery from tapered true lumen (arrow). Celiac axis vessels fill in retrograde fashion from superior mesenteric artery. tension and a prolonged ileus. Parenteral nutrition was stopped on the twelfth postoperative day as a full regular diet was instituted. The patient was discharged on the sixteenth postoperative day. Follow-up for 16 months has revealed no episodes of DISCUSSION Extension o f thoracic aortic dissection to involve the abdominal aorta is common. Shumacker et al.a documented abdominal aortic extension in 23 (69%) o f 33 patients treated for thoracic dissection. However, stenosis or obstruction o f the major abdominal aortic branches has been 0nly rarely reported. Gryboski and Spencer 4 presented a single patient with daudication from right iliac artery occlusion secondary to dissection. Transient renal failure from renal artery occlusion was reported by Mulder and Kaufman. s Shurnackcr ct al. 3 in 1975 reported a series o f 33 patients treated for acute thoracic aortic dissection. Five patients eventually suffered lower extrem-

3 474 Cogbill, Gundersen, and Travelli Journal of VASCULAR SURGERY \ J \ "II/ Fig. 4. Composite diagrammatic representation of aortographic findings indicating double-channel deformity of thoracoabdominal aorta with total occlusion of left iliac, celiac, and inferior mesenteric arteries. Patent false channel is shaded. ity vascular insufficiency secondary to iliac stenosis. In addition, abdominal aortic extension resulted in involvement of major visceral branches in five individuals. The renal artery was affected in four patients, the celiac axis in two, and the superior mesenteric artery in four. None of these patients exhibited symptomatic mesenteric insufficiency and none was treated surgically. To our knowledge, this article details the first reported case of claudication and symptomatic mesenteric insufficiency treated surgically after thoracic aortic dissection. This experience suggests several management considerations. Fig. 5. Diagram of procedure demonstrating end-to-end aortobi-iliac bypass graft with additional limb from graft to common hepatic artery. Proximal anastomosis is reinforced with Teflon pledgets. After acute aortic dissection has been treated ini. tially, patients must be carefully scrutinized for signs of renal, gastrointestinal, and peripheral vascular insufficiency. Careful documentation should be followed by accurate angiographic evaluation before proper operative preparations are made. This can be best achieved by biplanar aortography, including the entire length of the aorta below the level of dissection. The origin of each major abdominal aortic branch must be well localized in relation to the true or false lumen. Shumacker et al.s stressed that numerous direct communications between the two

4 Volume 2 Number 3 May 1985 Mesenteric insufficiency after dissecting aortic aneurysm 475 Fig. 6. Intravenous digital subtraction aortogram performed 16 months after reconstruction. A, Double-channel aorta persists distal to intrahmlinal prosthesis. B, Patency of hepatic limb (white arrows) and both iliac limbs (black arrows) of abdominal aortic graft is confirmed. "hannels distal to the site of the aortic intimal tear may maintain adequate flow to branches arising from either the false or true lumen. The true lumen is often markedly compressed with the majority of distal flow carried by the false lumen, as observed in this case. Surgical management of late stenotic sequelae of aortic dissection is only rarely discussed. Gryboski and Spencer 4 utilized excision of a portion of intima between the true and false channels to restore flow into the right common iliac artery, One of the patients with peripheral ischemia reported by Shumacker et al. required no surgical treatment and two responded to simple balloon catheter dilation. The other two patients were treated by inftarenal aortic replacement with Dacron tube grafts. The principle of infrarenal aortic resection and placement of interposition grafting to treat aortoiliac occlusion sec- ondary to cxtension from thoracic dissection was introduced by Hunter et al.6 in The present case is the first report of mesenteric vascular insufficiency and claudication treated surgically. Infrarcnal aortic resection with aortobi-iliac Dacron graft replacement and a separate Dacron limb to the common hepatic artery was successful. Secure proximal anastomosis was made possible utilizing interrupted horizontal mattress sutures with Teflon pledget reinforcement. Stenotic and obstructive lesions of the major aortic branches are an important aspect of the late consequences of acute aortic dissection. As the utilization of the intraluminal aortic graft becomes more widespread, 7s more patients may survive to experience these sequelae. A well-planned approach to evaluation and treatment is essential in the long-term management of these individuals.

5 476 Cogbill, Gundersen, and Travelli Jovial of VASCULAR SURGERY REFERENCES 1. DeBakey ME, McCollttm CH, Crawford ES, Morris GC, Howell J, Noon GP, Lawrie G. Dissection and dissecting aneurysms of the aorta: Twenty-year follow-up of five hundred twenty-seven patients treated surg!cally. Surgery 1982; 92: Miller DC, Stinson EB, Oyer PE, Rossiter SJ, Reitz BA, Griepp RB, Shumway NE. Operative treatment of aortic dissection. J Thorac Cardiovasc Surg 1979; 78: Shumacker HB, Isch JH, Jolly WW. Stenotic and obstructive lesions in acute dissecting thoracic aortic aneurysms. Ann Surg 1975; 181: Gryboski W, Spencer FC. Intermittent daudication caused by a dissecting aneurysm of the aorta. South Med J 1965; 58: Mulder DG, Kaufman JJ. Acute dissection of the thoracic aorta presenting as renal artery occlusion. J Thorac Cardiovasc Surg 1968; 56: Hunter IA, Dye WS, Javid H, Najafi H, Goldin MD, Serry C. Abdominal aortic resection in thoracic dissection. Arch Surg 1976; 111: Berger RL, Romero L, Chaudhry AG, Dobnik DB. Graft replacement of the thoracic aorta with a sutureless technique. Ann Thorac Surg 1983; 35: Krause AH, Chapman RD, Bigelow JC, Salomon NW, Okies JE, Page US. Early experience with the intraluminal graft prosthesis. Am J Surg 1983; 145: