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Emergency Management Of Thoracic Aortic Rupture With Combined Retrograde Stenting And Ascending Aortic Surgery, For Discussion Purposes
Mohamed Hassan.
University Hospital of Wuerzburg, würzburg, Germany.
Background: Thoracic aortic rupture is a life-threatening condition that requires immediate intervention to prevent catastrophic outcomes. While retrograde endovascular stenting has emerged as a valuable technique for stabilizing patients in critical conditions, its use in combination with open surgical repair for addressing concomitant aortic root and ascending aortic pathologies remains complex. This case report discusses the emergency management of a patient with thoracic descending aortic rupture, significant hemodynamic instability, and severe aortic insufficiency, who underwent a combined approach of retrograde stenting and open surgical repair. Methods: A female patient presented with massive hemodynamic instability caused by a rupture of the thoracic descending aorta. Emergency imaging confirmed the rupture along with severe aortic valve insufficiency severe left ventricular dysfunction and an ascending aortic diameter of 6.5 cm. The patient was immediately taken to the operating room. Initially, retrograde stenting of the descending aorta was performed to stabilize the hemodynamics. Due to sustained haemodynamic instability, the decision was made to proceed with open surgical repair in the same session. A median sternotomy was performed, and the procedure included reconstruction of the aortic root, replacement of the aortic valve, and replacement of the ascending aorta. The surgery was completed successfully, and the patient was hemodynamically stable postoperatively. Results: The initial postoperative course was uneventful, and the patient demonstrated stable hemodynamics. However, three days postoperatively, the patient developed neurological deficits in the form of paraplegia. Neurological evaluation suggested spinal cord ischemia as the likely cause. Over time, partial recovery of neurological function was observed with intensive rehabilitation. No further complications were noted during the hospital stay. Conclusion: This case highlights the challenges associated with managing complex aortic pathologies in emergency settings. While retrograde stenting and open surgical repair offer a life-saving option, they carry risks such as spinal cord ischemia. To mitigate such complications, preventive measures, including permissive hypertension and early placement of cerebrospinal fluid drainage, should be considered. Future protocols should integrate these strategies to improve neurological outcomes and reduce the risk of paraplegia in similar cases.
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