Results of Coronary Stenting using the Stents with

Интервенционная Cardiovascular ангиология
surgery
limitation of dissection, minimization of
the impact on the aortic wall, prevention
of dilatation and creation of conditions
for false lumen thrombosis. Surgical
mortality can be as high as 30% or even
more (5).
Concomitant aortic valve insufficiency,
ring and aortic root dilatation
present in 50-60% of cases of aortic
dissection usually require surgical aortic
valve replacement, or aortic valve replacement
with ascending aorta grafting
using Bentall-De Bono technique,
or valve-preserving surgery using David
and Yacoub technique.
The fenestrations in the aortic arch
occur in 30% of dissection cases. In
case of fenestrations in the aortic arch,
distal anastomosis between the graft
and the aorta is performed to bypass a
part of aortic arch, not involved in dissection.
In any case, if prolonged multiple fenestrations
extend beyond the site of aortic arch passage
into the descending part of the aorta, it is necessary
to perform subtotal or total arch replacement with
rebranching of several or all aortic branches into the
graft. This is performed in the settings of hypothermic
circulatory arrest and antegrade cerebral perfusion.
If the dissection involves also the descending
aorta, the “elephant trunk” aortic arch reconstruction
is indicated.
Most patients with aortic dissection are severely
ill and unlikely to survive traditional open surgical intervention
with deep circulatory arrest, aortic arch reconstruction,
etc. Such high-risk patients, as well as
the complications occurring during open heart surgery
and pharmacological therapy, have stimulated
the search of new technologies for the treatment of
aortic dissections — minimally invasive endovascular
interventions.
In general endovascular treatment is being used
for both types of aortic dissection — A and B, —
both in acute and in chronic forms. Recent results
of meta-analyses have shown technical feasibility of
endovascular intervention in 98% of cases, as well
as encouraging immediate and mid-term results
(1-2 years) (6, 7). The advantages of endovascular
interventions and hybrid surgery for aortic dissections
in comparison with traditional open surgery are
evident. In particular, endovascular approach allows
to avoid thoracotomy with subsequent formation of
pleural adhesions (8-11). Usually the procedure is
performed through the femoral approach. Unlike
open operation, primary or repeated endovascular
intervention can be performed under spinal or even
local anesthesia. It is evident that in high-risk patients
endovascular interventions have significant advantages
over surgical treatment and offer hope for
recovery for patients with contraindications for open
surgery. These advantages comprise the decreased
Fig. 1. MHCT of patient Z
rate of mortality and complications, the minimization
of time spent in the ICU and in hospital, as well as of
postoperative rehabilitation.
Innovative hybrid surgical approach as a method
of effective revascularization, combines the effectiveness
of traditional open surgery and of percutaneous
endovascular intervention with balloon valvuloplasty
and endograft implantation. Due to its minimal invasiveness,
the hybrid approach allows to minimize
the complications and to decrease the mortality in
high-risk patients. In case of lower limb ischemia this
approach is preferable for legs perfusion using extracorporeal
circulation.
Clinical case
The purpose of our paper is to present a clinical
case of successful two-stage correction of type I aortic
dissection using hybrid surgical approach.
A 52-years-old woman was admitted to the Department
of Cardiovascular Surgery on September 10,
2009 with complaints of restrictive retrosternal pain
associated with minimal physical load, palpitations
and pulsation of the neck vessels. History analysis
revealed that the patient had poorly controlled
arterial hypertension for over 20 years (max. BP
190/110 mm Hg). She has considered herself sick
from May 20, 2009, when in the night she suddenly
felt an intensive retrosternal pain irradiating into the
neck and the mandible. After 40 minutes the pain
has been stopped with Nitroglycerin. In-hospital examination
excluded myocardial infarction, EchoCG
revealed severe aortic valve insufficiency. Within
2 weeks after the pain attack her body temperature
remained high — 38 0 С. Her condition at admission
was severe, with respiration rate at rest — 25/
min. and visible pulsation of the cervical vessels. A
loud diastolic murmur heard over the whole heart,
radiating to the carotid arteries, interscapular
space, as well as a systolic murmur with maximal
48
(№ 26, 2011)