Early malperfusion, ischemia reperfusion injury, and respiratory failure in acute complicated type B aortic dissection after thoracic endovascular repair.

0.35 MB·English

by  Xiong, Jiang

Xiongetal.JournalofCardiothoracicSurgery2013,8:17
http://www.cardiothoracicsurgery.org/content/8/1/17
RESEARCH ARTICLE Open Access
Early malperfusion, ischemia reperfusion injury,
and respiratory failure in acute complicated
type B aortic dissection after thoracic
endovascular repair
Jiang Xiong, Minhong Zhang, Wei Guo*, Xiaoping Liu, Tai Yin, Xin Jia, Hongpeng Zhang, Yongle Xu
and Lijun Wang
Abstract
Background: The aim of this study was to determine the early mortality and major complicationsofacute
complicated type Baortic dissection (ACBD) after thoracic endovascular aortic repair (TEVAR).
Methods: Twenty-six consecutive patients with ACBD who underwentTEVAR were included.Clinical indications
before TEVAR and in-hospital mortality and major complicationsafter TEVAR were analyzedand compared with
similar reports.
Results: TEVAR was technically successful inall cases. In-hospital mortality occurred infour patients (15%), and
major complicationsoccurred inan additional four patients (15%). Three of thefour (75%)of the deaths were
associated with malperfusion and ischemia reperfusion injury (IRI), and 3/4(75%)of the major complicationswere
caused by respiratory failure (RF).
Conclusions: In-hospital mortality associated strongly with severe end-organ malperfusion and IRI, whilemajor
complications associated with RF,during TEVAR.Our results indicate that malperfusion, IRIand respiratory failure
during TEVAR should be carefully monitored and aggressively treated.
Background complications of TEVAR include permanent renal fail-
Thoracic endovascular aortic repair (TEVAR) is the ure, stroke, paraplegia, and respiratory failure (RF). An
promising treatment for acute complicated type B aortic analysis of early mortality and major complications, with
dissection (ACBD) [1-4]. During the acute phase of the the exclusion of procedure-related factors, would pro-
dissection,TEVAR can obviate impending aortic rupture vide a better understanding of the impact of TEVAR on
and relieve dynamic malperfusion [5,6]. A delayed bene- ACBD outcomes and provide insight in the clinical deci-
fit is potentiation of thrombosis within the thoracic false sions of when to use TEVAR and when to add adjuvant
lumen, thereby mitigating the risk of aneurysmal dilata- therapy to the TEVAR procedure. Therefore, this study
tion and subsequent aortic rupture [7-9]. TEVAR is su- focused on ACBD patients to identify indicators that
perior to conventional surgical repair, which is more could predict in-hospital mortality or major complica-
invasiveandhasmore potential complications. tionsduringTEVAR.
Despite the short-term benefits (low morbidity and
mortality) of TEVAR for the repair of ACBD [1,4], an
increasing number of studies report early mortality and Methods
major complications after TEVAR [7,10-12]. Major Patients
From March 2004 to October 2010, 26 consecutive
patients with ACBD underwent TEVAR in our depart-
*Correspondence:[email protected]
ment. TEVAR was performed less than 14 days after the
DepartmentsofVascularSurgery,ClinicalDivisionofSurgery,ChinesePLA
GeneralHospital,Beijing,China onsetofsymptomsinallcases.Theclinicalcharacteristics
©2013Xiongetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative
CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.
Xiongetal.JournalofCardiothoracicSurgery2013,8:17 Page2of7
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of the patients are listed in Table 1. All the patients had system dilator–sheath was advanced into the aortic true
confirmedStanfordtypeBdissectionbycomputedtomog- lumen, and the stent graft was advanced to completely
raphy (CT) angiography. ACBD was diagnosed according cover the primary intimal tear. The systolic blood pres-
to the signs and symptoms, including severe end-organ sure was lowered to less than 100 mmHg, and the heart
malperfusion, persistent pain, acute aortic failure, refrac- rate was lowered to below 90 beats/min. In order to
toryhypertensionandencephalopathy. exclude false lumen flow, the stent graft was delivered
under fluoroscopic guidance to cover the primary in-
Techniques timal tear. Ballooning of the stent graft was performed
Before the endovascular procedure, CT angiography was only if a large type Ia proximal endoleak was documen-
used to measure the distance and diameter of the landing ted, and ballooning occurred only at the proximal land-
zone, which is the normal part of the aorta used to attach ing zone. When needed, a second stent graft was placed.
the stent graft during the TEVAR procedure. During the Angiography confirmed the absence of endoleaks and
procedure, the landing zone diameter was determined by determined the perfusion status of the previously ische-
digital subtraction angiography. The diameter of the mic arterial beds. Technical success was determined by
selectedstentgraftwas10-20%largerthanthelandingzone exclusion of proximal primary entry flap on the comple-
diameter.Allprocedureswereperformedinanangiography tion angiogram. The details of TEVAR procedures are
unit (INNOVA 3100, GE Medical Systems, Milwaukee, listedinTable2.
WI). Local anesthesia was used in two cases due to pre- ACBD patients with severe end-organ malperfusion
existing cardiac and respiratory dysfunction, while general who underwent TEVAR were administered prophylactic
anesthesiawasperformedintheremaining24cases. hemodialysis.Inthe caseofACBDwithseveremalperfu-
Allstentgraftsweredeployedwiththecommonfemoral sion, the important organs affected were the kidney, the
artery approach via unilateral femoral access. It was not intestine and the lower extremities. Severe end-organ
necessary to use conduits for any of the cases. The tech- malperfusion was empirically defined as the appearance
nical details of TEVAR have been described by Nienaber
[13]. Once the true lumen wire access through the left
Table2TEVARprocedurecharacteristics
brachialarterywasconfirmedintheascendingaorta,arch
Variable Number(%)
angiographywasperformed.Ifimagingindicatedtheneed
Timeintervalbetweensymptomonsetand
forleftsubclavianarterycoverage,selectivevertebralangi-
procedure
ographywasperformedtoevaluatetheadequacyofcollat-
(d;Mean±SD(Range)) 7.8±4.4(1–14)
eral vertebral artery flow and to confirm the absence of
Stentgraftoversizingaortadiameteroflanding
internalmammarygrafts.
zone
Patients were systemically heparinized with a dosage
10% 20(76.9)
of100IU/kgbyintravenousbolusinjection.Thedelivery
15% 4(15.4)
Table1BaselinecharacteristicsandCTfindings 20% 2(7.7)
Variable Number(%) Sizeofthestentgraft#(mm;mean±SD(Range))
Sex(Male/Female) 23/3 Proximaldiameter 33.7±3.6(28–40)
Age(y;Mean±SD(Range)) 52.8±13.1(31–72) Distaldiameter 33.4±3.8(28–40)
Descendingaortadimension(mm;Mean±SD 29.0±2.7(23–36) Graftlength 127.6±29.2(60–
(Range)) 162)
PatientsindistancefromLSCAtoprimarytear Coverageofbranchartery
<1.5cm 13(50.0) LSCAcoverage 9(34.6)
>1.5cm 13(50.0) LSCAdominant 2(7.7)
Truelumenappearance AberrantRSCAcoverage 1(3.8)
Patent 20(76.9) LCCAcoverage 2(7.7)
SevereStenosis(location)# 2(7.7) PartialLCCAcoverage 1(3.8)
Thoracicaorta 1(3.8) Lengthofaortacovered(cm;mean±SD(Range)) 13.5±2.9(6–18)
Commoniliac 1(3.8) Operationtime(h;mean±SD(Range)) 2.2±1.1(1–6.4)
Occlusion 4(15.4) Contrastvolume(ml;mean±SD(Range)) 190±61.2(100–
350)
Abdominalaortabelowtherenalartery 1(3.8)
LSCA-leftsubclavianartery;RSCA-rightsubclavianartery;LCCA-leftcommon
Commoniliac 3(11.5)
carotidartery.
LSCA-leftsubclavianartery;#Diameterdecreasedmorethan80%. #Twostentgraftswereimplantedinonepatient.
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of any one of following indicators: Type II extremity is- Six types of stent graft systems were used, including
chemia [14], intestine malperfusion related hematoche- Talent (Medtronic Inc, Minneapolis, MN; n=11),Valiant
zia or hematemesis, blood creatinine level≥500 μmol/L, (Medtronic Inc, Minneapolis, MN;n=8),Zenith(COOK,
or blood creatine kinase≥10000 IU/L. According to em- Inc, Bloomington, IN; n=1), Endofit (Endologix Inc,
pirical indicators of the severe end-organ malperfusion, Irvine, CA; n=3), Hercules (Microport, Shanghai, China;
patients with more than two indicators were adminis- n=4)andAnkura(Lifetech,Shenzhen,China;n=2).One
tered prophylactichemodialysisafterTEVAR. stent graft was implanted in 25 patients, and two stent
grafts were implanted in one patient to cover multiple
Datacollectionandstatisticalanalysis tears on the distal descending aorta. The coverage dis-
Data collected included age, survival status, graft compo- tance between the left common carotiod artery (LCCA)
nents utilized, access arteries, subclavian artery coverage, andtheprimarytearwaslessthan15mmintwopatients.
lengthofin-hospitalstay,major/minorin-hospitalcompli- Technicalsuccesswasachievedinallpatients.Delivery
cations, and status of the false lumen immediately after system via the femoral approach was successful in all 26
procedure. Major complications were defined as events patients, requiring unilateral incision in 24 cases, bilat-
that were life threatening or would prompt major thera- eral femoral incisions in one case, and unilateral incision
peutic consequences (e.g., access complications requiring with contralateral percutaneous access in one case. Im-
surgical revision, re-interventional treatment or requiring mediate postoperative angiography showed no re-entry
dialysis).Minorcomplicationsweredefinedasthatnofur- site at the distal end of the false lumen of six patients
ther treatment was required (e.g., transient renal failure with ACBD. The blood supply of visceral arteries via the
notrequiringdialysisortransientspinalcordischemia). falselumenwasfound intheremaining20cases.
This was a retrospective, non-comparative analysis. All Twenty patients (77%) required intensive care unit
statistical data were descriptive on an intent-to-treat (ICU) monitoring and continuous intravenous infusion
basis. Discrete variables were presented as percentages, of antihypertensive agents. The average length of hos-
while continuous variables were presented as counts and pital staywas13.8±9.9days (range, 1to38days).
are presented as mean ± SD. The ethical approval for Based on the angiographic findings and patient symp-
this study was provided by the Ethical Committee of the toms, all patients with malperfusion had immediate
Chinese PLAGeneralHospital. resolution of the malperfusion deficit after the proced-
ure. Endoleaks were detected in six patients using pro-
Results cedural angiography; five with Type Ia endoleak, in
Proceduraldata which left subclavian artery was covered in three cases,
Symptomatic indications for intervention included per- and one with aType II endoleak. All patients with endo-
sistent pain (23 patients), malperfusion (10 patients), leakswereuntreatedintheprocedure.
aortic failure (8 patients), and refractory hypertension
(5 patients). Multiple indicators were present in 16 In-hospitaldeathsandmajorcomplications
patients (Table 3). Clinical data for the patients who died or had major
complications are summarized in Table 4. Four patients
Table3IndicatorsforTEVAR died and four patients experienced major complications
following TEVAR. In these patients, the average length
Indications n
of stay in the ICU was 12.9±9.8 days (range, 0 to
Malperfusion 10(38.5%)
29 days) after the procedure. Three deaths were attribu-
Lowerextremityischemia 4
ted to pre-existing organ malperfusion and ischemia
Paraplegia 2 reperfusion injury (IRI), and one was attributed to RF,
Renalarterymalperfusion 7 respiratory infection, and renal failure (Table 4). An in-
SMAmalperfusion 6 dependent Clinical Events Committee adjudicated that
all deaths were not related to the TEVAR procedure
Refractoryhypertension/encephalopathy 5/2(19.2%)
itself.
PersistentPain 23(88.5%)
In six patients with SMA malperfusion and a bloody
Chestpain 14
stool, two died and one had a major complication after
Abdominalpain 16 the procedure. Of the other three patients, all survived
Aorticfailure 8(30.8%) without any symptoms of intestinal ischemia. In four
Acutetruelumencollapse 3 patients with lower extremity malperfusion, two patients
had Type III ischemic mottling who died after the
Severepleuraleffusion 6
procedure. One patient had no pulse, pallor, and
Twelvepatientshadtwoindicationsandfourpatientshadthreeindications.
SMA:superiormesentericartery. paresthesia, but he survived once the lower extremity
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Table4Patientoutcomes
Outcome Sex/Age Clinical Indicatorsof Causeofdeath Malperfused Onset Malperfused Lengthofstay
indications severeend- ormajor branch timeto brancharteries postprocedure
organ complication arteries procedure afterprocedure
malperfusion before
(number) procedure
Death M/58 Abdominalpain, 3 IRI,MOF Occlusionof 48h OpenofleftRA 9d(ICU9d)
paraplegia, bilateralRA (doublelumen
bilaterallow andinfrarenal supply),rightRA
extremity aortatrue (falselumen
ischemicmottling lumen supply)and
(typeIII)a,arterial collapse infrarenalaorta
hypertension (truelumen
supply)
Death M/39 Abdominalpain, 3 IRI,MOF Occlusionof 15h Openofbilateral 2d(ICU2d)
hematochezia, SMA,bilateral RA(truelumen
hematemesis RA supply),SMA
dissection
Death M/31 Abdominalpain, 3 IRI,Intestinaltract Occlusionof 13h OpenofSMA, 7h(ICU7h)
hematochezia,left necrosis SMA,rightRA rightRAand
lowextremity andrightCIA rightCIA(true
ischemicpallor lumensupply)
andsuggillation
(typeIII),arterial
hypertension
Death M/61 Arterial no ARDS,renalfailure, None 8d None 29d(ICU29d)
hypertension, respiratory
encephalopathy infection,
encephalopathy
Live M/65 Chestpain,arterial no ARDS,acute None 52h None 31d(ICU24d)
hypertension hepaticfailure,
respiratory
infection
Live M/41 Tarstool 2 ARDS,respiratory Occlusionof 11d OpenofrightRA 12d(ICU11d)
infection, rightRAand andCIA(true
hydropericardium, CIA lumensupply)
pleuraleffusion
Live M/32 Obesity,pleural no ARDS,Respiratory None 7d None 34d(ICU16d)
effusion infection
Live F/39 Abdominalpain, 2 Intestinalischemia, Occlusionof 4d OpenofSMA, 38d(ICU11d)
hematochezia intestinalinfection, SMA,rightRA rightRAandleft
ischemic andleftEIA EIA(truelumen
pancreatitis supply)
RA,renalartery;SMA,superiormesentericartery;CIA,commoniliacartery;MOF,multipleorganfailure;ARDS,adultrespiratorydistresssyndrome;EIA,external
iliacartery;IRI,ischemicreperfusioninjury.aTheclassificationoflowextremityischemiawasfromreference14.
malperfusion was relieved. In seven patients with renal patient with tracheal intubation for 16 days had RF and
malperfusion before the procedure, only one patient had respiratoryinfection.
renal dysfunction after the procedure. Three patients Two patients had minor complications. One patient
with three indicators of severe end-organ malperfusion had a headache that resolved five days after the proced-
died even though hemodialysis was administered after ure. The other patient had right low extremity malperfu-
TEVAR(Table4). sion and transient renal failure, but recovered one week
In four patients with major complications after the after the procedure without the need for dialysis. In 23
procedure, three had RF and respiratory infection. An- patients with persistent chest or abdominal pain before
other patient had pre-existing organ malperfusion and the procedure, three died from malperfusion and IRI,
IRI. In four patients with RF after the procedure, the while three of the survivors had persistent chest and
duration of tracheal intubation was 20±7.8 days (range, abdominal pain that was unrelieved. In five patients with
11 to 29). Only one patient had severe pleural effusion refractory hypertension before the procedure, one died.
before the procedure. In six patients with severe pleural Of the remaining four survivors, three patients had
effusion after the procedure, five accepted tracheal refractory hypertension that resolved on its own. Except
extubation immediately after the procedure, while one for one pre-procedural paraplegia patient, none of the
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surviving patients had complications requiring further failureand death after TEVAR. Ifend-organmalperfusion
treatmentatthe timeof hospitaldischarge. is more serious, then the IRI will be more serious after
TEVAR and early mortality will consequently be higher.
Follow-updata In-hospital mortality following TEVAR occurred in three
All 22 in-hospital live patients were followed up from 1 of the 10 patients with malperfusion and accounted for
to 49 months (average, 6.8±7.3 months). The type Ia three of four (75%) in-hospital deaths. In similar single-
endoleak in 4 patients spontaneous resolved at one centerstudies,Pearce[16]andSzeto[4]reportedahigher
month. The endoleaks in another 2 patients (1 with type proportionofmalperfusion(Table5),butnomalperfusion-
Ia and 1 with type II) were observed at three month. relatedmortality.Inothersimilartwosingle-centerstudies,
Two deaths occurred at 2 and 3 months and the reasons Khoynezhad [17] and Feezor [6] reported a higher
were unclear. One late deaths was as the result of pul- proportion of malperfusion (Table 5) and significant
monarycarcinomaat 24months. malperfusion-related mortality rates (7% and 13.3%,
respectively). In our study, the three malperfusion-related
Discussion deaths occurred in patients who had severe malperfusion
Both dissection rupture or imminent rupture and mal- and IRI of one or two end-organs. In studies by Pearce
perfusion are indicators for emergency TEVAR in a pa- [16],Szetodl[4],Khoynezhad[17]andFeezor[6],informa-
tient with ACBD [15]. In fact, imminent rupture is tion regarding the degree of end-organ ischemia was not
difficult to determine clinically in a patient with ACBD, included.Classificationofthedegreeofend-organmalper-
and dissection rupture is more rare than malperfusion fusionwouldhelppredictthemortalityrateafterTEVAR.
[9,15,16]. The most significant findings of this study In the process of TEVAR, many surgeons use surgical
were that in-hospital mortality associated with severe or interventional fenestration [18,19] or branch vessel
end-organ malperfusion IRI and major complications stenting [6] to handle persistent malperfusion. There are
associated withRF duringTEVAR. few reports about the process of IRI in malperfusion
There were 10 patients (38.5%) with malperfusion in with anopenend-organartery.
our group; however, no patients showed evidence of dis- In our study, three of five ACBD patients with severe
section rupture or imminent rupture. In previous single- malperfusion suffered IRI, multiple organ failure, and
center studies, malperfusion was a common indicator in-hospital death even though they received prophylactic
among patients (Table 5). Before our study, the poor hemodialysis post-TEVAR. We found that the clearance
prognosis of malperfusion had not been systematically of metabolic toxins was poor in improving survival of
analyzed. Compared with other indicators, including severe malperfusion ACBDs. For these patients, removal
refractory hypertension, persistent pain and aorta failure, of severe malperfusion end-organs may be acquired
malperfusion is a more urgent indicator for emergency more beneficial than re-opening the end-organ artery.
TEVAR. Thisis due to the fact that end-organ malperfu- Currently, more published reports of ACBD have been
sion and subsequent life-threatening organ failure are concerned how to reopen malperfusion end-organ arter-
imminent results. In addition, the severity of ACBD ies in TEVAR [3,6,15,20-24]. Fenestration and stenting
malperfusion and IRI appear to be more closely related have been used frequently, and prosthetic bypass has
to early mortality following TEVAR than the other been usedinvisceralmalperfusion.
complications. There are few reports detailing when malperfusion
After TEVAR, the malperfused end-organ artery may persists to result in end-organ ischemia, nor are there
opencausingearlyIRI.Irreversiblemalperfusionandearly any reports regarding the assessment of the degree of
IRIcanincreasethesystemicabsorptionofmetabolictox- end-organ malperfusion, IRI severity and reversibility of
ins, which may become a direct cause of multiple organ malperfusion end-organ function in TEVAR therapy. In
our study, the cause of three ACBD patient deaths were
Table5MalperfusionproportioninACBDpatients
malperfusionandIRI,who hadmorethantwoindicators
Study Malperfusion(n) ACBD(n) Proportion of severe end-organ malperfusion (Table 4). On the
Szeto[4] 17 35 48.6 other hand, two malperfusion ACBD patients who sur-
Feezor[6] 11 33 33.3 vived had only two indicators (Table 4). The other five
malperufsion ACBD patients who survived had no indi-
Conrad[7] 17 33 51.5
cators of severe end-organ malperfusion. Re-opening the
Parsa[12] 11 22 50
malperfusion artery is not a unique option. We propose
Pearce[15] 8 15 53.3
that nonreversible end-organ malperfusion is an indica-
Khoynezhad[16] 15 28 53.6 tion for primary surgical removal of end-organs (e.g., ex-
Botsios[17] 6 32 18.8 tremity amputation, intestine resection). Some centers
ACBD=acutecomplicatedtypeBaorticdissection. have reported a little experience of organ resection, but
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the organ removal indicators, primary surgical risk and correlation between RF and systemic inflammation re-
postoperative prognosis is still unknown [9,21]. Our maintobefurther understood.
study suggests that a number of indicators of severe The most effective prevention and treatment of IRI is
end-organs malperfusion could become the basis of mal- to restore blood flow as early as possible. Procedures to
perfusion organ removal or malperfusion organ artery improve the perfusion to ischemic end-organs should
re-opening. notbe delayed only because offear of reperfusion injury,
RF occurred postoperatively in four patients, including unlessirreversible ischemia hasbeenproved.
one who died. The cause of postoperative RF was not
clear because these patients had no pulmonary disease Abbreviations
ACBD:AcutecomplicatedtypeBaorticdissection;TEVAR:Thoracic
orseveremalperfusion,withtheexceptionofonepatient
endovascularaorticrepair;IRI:Ischemiareperfusioninjury;RF:Respiratory
who had preoperative pleural effusion and obesity. In failure;CT:Computedtomography;LCCA:Leftcommoncarotiodartery;
regards to the possible causes of respiratory failure, it ICU:Intensivecareunit.
has been reported that ischemia and reperfusion of in-
testine, renal, and lower extremity may cause distant
Competinginterests
pulmonary injury. Feezor et a.l [6] reported that 11 of 33 Theauthorsdeclarethattheyhavenocompetinginterests.
ACBD patients who underwent emergency TEVAR suf-
Authors’contributions
fered RF without any apparent underlying cause. Add- JXandWGcarriedouttheconceptionanddesign.JX,MZandWGcarried
itionally, Sachs [25] showed respiratory complications outtheanalysisandinterpretation.JX,MZ,XL,TY,XJ,HZ,YXandLW
participatedinthedatacollection.JXparticipatedinthewritingthearticle,
accounted for 4.3% of type B dissections after TEVAR.
thecriticalrevisionofthearticleandthestatisticalanalysis.Allauthorsread
Kurabayashi [26] demonstrated that the only independ- andapprovedthefinalmanuscript.
ent predictor of oxygenation impairment was acute aor-
Received:1September2012Accepted:8January2013
tic dissection (odds ratio, 1.323; 95% confidence interval,
Published:23January2013
1.035-1.691, P=0.026). This study proposed that RF in
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