A Dual Dilemma: Management of Acute Aortic Dissection in the Setting of Preexisting Abdominal Aortic Aneurysm
Corbin Muetterties1, Steve DeBeer2, Grayson Wheatley, III1.
1Temple University School of Medicine, Philadelphia, PA, USA, 2Emory University, Atlanta, GA, USA.
OBJECTIVE: Acute aortic dissection (AAD) occurring in patients with a pre-existing abdominal aortic aneurysm (AAA) presents a challenging treatment dilemma. Extension of the dissection flap into the lumen of the AAA can potentially change its suitability for endovascular repair. Limited knowledge exists about how best to approach this unique aortic pathology. In an attempt to address this question we discuss our experience with this problem along with a comprehensive review of the literature.
METHODS: We reviewed our institutional aortic database for patients with preexisting AAA and AAD treated at our institution. In addition, we performed multiple PubMed queries for peer-reviewed publications using the search term “AAA with concurrent dissection” and the terms “repair” “aortic dissection” “aortic aneurysm” and “thoracoabdominal”. Papers that described surgical or endovascular management of patients with coexisting AAA and AAD in native aortas were included.
RESULTS: Three patients with preexisting AAA and subsequent AAD were treated at our institution (1 endovascularly and 2 medically). There were no strokes, paraplegia, or deaths within 30 days follow-up. Figure 1 shows a concurrent AAA and AAD with a thrombosed false lumen treated at our institution. The PubMed query revealed a total of 6 papers describing the surgical management of patients with coexistant AAA and AD. 16 patients were treated with open surgery while 2 patients were treated endovascularily. In two patients (1 open and 1 endovascular) fenestration of the aortic septum was completed at the time of intervention. Type II endoleak was reported in 100% (2/2) of cases treated endovascularily, however neither required reintervention. Overall mortality was 37.5% (6/16) and 0% (0/2) for open and endovascular surgery respectively. Of the patients who perished, two died intraoperatively, three from aortic rupture, and one due to acute renal failure.
CONCLUSIONS: AAD and AAA presenting as coexistent conditions is rare and clinical experience is limited with regards to optimal therapy. We propose that endovascular therapy, when feasible, may provide a safe and effective intervention, however further study is needed.
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