Fulminant course of visceral malperfusion due to type B aortic dissection
Aortic type B dissection can be treated conservatively in up to 90% of uncomplicated cases. Additional symptoms comprising of the pain in the thorax and abdominal cavity may suggest vascular complications. Visceral ischemia is observed in about 30% of aortic dissections. Synchronous symptoms in the thorax and abdomen are very rare situation. A 54-year old male patient was admitted to the clinic on duty with diagnosis of aortic dissection. Angiotomography proved a dissection starting just below the origin of the left subclavian artery and running along the aorta to the external iliac arteries. The patient presented also with very high systemic pressure and abdominal symptoms of diffuse peritonitis. Plain abdominal x-ray proved perforation of his gastroalimentary tract. Emergency laparotomy was performed disclosing a vast defect of gastric walls in the prepyloric region and visible ischemia of mucosa with patches of necrosis reaching up to the half of the stomach. B II resection was performed with anastomosis of the stomach stump to the small intestine on so-called Lahey loop. Histological evaluation did not prove the existence of peptic ulcer. In the postoperative period ischemia of the intestines was observed again. The afferent loop of gastrointestinal anastomosis was shrunken due to this fact. Patient received wide spectrum antibiotics and was maintained on total parenteral nutrition. Apart from this treatment the state of the patient did not change. It was decided that closure of the entry tear in the thoracic aorta was the only way to restore a proper blood flow in it. Aortic stent-graft was implanted to the thoracic aorta descending to the level of the celiac trunk despite the symptoms of septicemia. This endovascular procedure changed the blood flow in the thoracic aorta and improved the inflow to visceral arteries but the patient was operated two more times because of progressing necrosis in the vicinity of intestinal anastomoses with fistulae formation. Finally the patient recovered within three months since admission. He also experienced stroke during his hospital stay. Type B aortic dissection complicated with visceral ischemia requires an urgent surgical treatment. Aortic stent-graft placement seems to be the gold standard in such cases. This treatment should precede formation of intestine necrosis with fistulae and subsequent septic complications. It seems that regaining of the true channel below the stent-graft may require certain time for the shrinking of the false one filled with thrombi does not appear just after the endovascular procedure.
Keywords: aortadissectionstent-graftischemiaabdominal cavitycomplications