Dr Anil Dhall, Director, Cardiovascular Sciences, Venkateshwar Hospital, Delhi
The aorta is the largest artery of the body carrying blood from the heart. A dynamic tea r within its wall can lead to a devastating medical condition called aortic dissection. Aortic dissection leads to the creation of a large false lumen and weakens the aortic wall as well as compromises the blood supply of the vessels arising from the false lumen. Dissections arising in the ascending aorta close to the heart are usually fatal as they have cardiac complications and need to be treated surgically. Today, we have means to treat dissections in the descending aorta by percutaneous endovascular methods, wherein a large fabric-covered stent is placed in the true lumen to strengthen the vessel wall and to ensure adequate blood supply to the branches. However, to enable the fabric-covered stent to seal the entry, it should have at least 2 cm fixation in the normal vessel.
We recently had a 42-year-old male who was transferred to our center from Orissa with features of aortic dissection involving the descending aorta. A CT angiogram revealed that we did not have adequate normal aorta to ensure proximal seal without compromising the blood supply of the brain.
The patient was evaluated by our Heart Team. To achieve the desired results, it was decided to perform a hybrid procedure.
At first, the blood supply to the brain was surgically bypassed with grafts being placed from ascending aorta to both carotid arteries. Once the blood supply to the brain was secured, it was planned to take a stent graft from the leg to seal the dissection.
However, the aortic dissection had created multiple planes and it was mandatory to confirm that our wire, over which we were to deploy the stent graft, was in the true lumen as deploying a stent graft in the false lumen would have catastrophic consequences.
Venkateshwar Hospital is fully equipped with all modern state-of-the-art gadgetry and experienced human resources. The hospital has high-end operation theaters as well as the latest cath lab with many special tools including intravascular ultrasound.
We decided to reconfirm the passage of the guide wire by conducting an intravascular ultrasound (IVUS). The IVUS showed us a view of the aorta from within and clearly showed us that we were in the true lumen. Though IVUS is available is several cath labs across the country and is used for coronary interventions, there is limited experience of use of IVUS in the aorta or the peripheral arterial tree and to the best of our knowledge, this may be the first time that a 10 MHz IVUS has been used to guide an endovascular repair of the aortic dissection.
The Heart Team is a collaborative effort between the cardiologist and cardiac surgeons, which can enable the best therapeutic decisions for a patient as well as pave the pathway for hybrid therapies such as these.
Venkateshwar Hospital is committed to a Heart Team approach and is equipped with all the latest equipment including rotablator, EP system, and ECMO besides the IVUS.