Dear Editor:
Henn et al.[1] have nicely described a case scenario whereby a penetrating atherosclerotic ulcer
(PAU) of the descending aorta extends with intramural hematoma (IMH) into the ascending
aorta. For those of us who manage a lot of acute aortic pathology, this clinical scenario
occurs not that infrequently. Based on the dictum that all type A pathology is treated
first, the question is whether these patients should be managed by replacement of
their ascending aorta first with subsequent repair of their PAU at a later date. Should
the ascending be repaired and then insert an endograft distally in an open technique
in the same setting? Or should we do as the authors have suggested: just treat the
PAU with a covered stent endograft in the descending thoracic aorta? Surprisingly,
there is little literature or data to help us manage this clinical scenario.
In the present case report, the authors describe a case in which a stent graft was
placed in the descending thoracic aorta with subsequent resolution of the ascending
aortic IMH. I personally have done this before, as well, with mixed results. There
are multiple questions that remain unresolved about this scenario (and others I am
sure our readers have asked). For example, does one balloon the endovascular prosthesis
that was used to treat the PAU? Is it safe to carry a wire over into the arch and
ascending aorta? What is the risk of creating a true type A dissection in these patients?
Finally, what are the criteria for a spinal drain in these cases?
One might also ask the authors what was their plan, had the IMH in the ascending aorta
progressed to a full blown dissection both acutely and chronically; a reverse elephant
trunk with repair of the arch, or just repair of the ascending aorta? Does having
a stent graft in place change the management of these complex patients and almost
ensure that circulatory arrest is required to remove the stent graft placed for a
PAU?
I am reminded of two things in particular associated with this case, as the technical
performance of an endograft in this position is not difficult. However, as a vascular
surgeon, it would be imperative that I have a thorough discussion of this case with
my cardiac surgery partners before taking a case like this one on (no matter how technically
easy it is!). Second, I remember when Drs. Mike Deeb and Dave Williams at the University
of Michigan started treating all of the type A dissection patients with malperfusion
by fenestration and stenting first, prior to taking the patients to the operating
room for their type A repair. At the time, this approach was believed to be heresy
by some. Yet, they persevered and many patients were saved with renal, mesenteric,
and spinal arteries perfused (i.e., few patients with dead gut, on dialysis, or paralyzed)
with nearly identical improved mortality rates compared to those patients who were
just taken straight to the operating room with malperfusion. It should give us all
pause to think that maybe just treating the PAU in the present scenario was the right
thing to do. Congratulations to the authors.
