Ann Thorac Surg
2006;82:7479
Fig 2. Angiographic image after stent implantation. Pulmonary ar-
tery is well dilated (black arrow).
line. Cardiac arrest lasted for approximately 30 seconds
and endovascular maneuvers were performed. Alto-
gether, four temporary arrests were necessary for dila-
tion and stent implantation (Fig 2). Immediately after
stent placement, the central venous oxygen saturation
increased from 68% to 78%, whereas the central venous
pressure decreased to 10 mm Hg. After removal of the
central endovascular catheters, the patient was weaned
from ECC without difficulty. The femoral cannulas were
removed and the groin was closed. During all measures
and maneuvers our patient remained responsive and
comfortable. The following clinical course of the patient
was uneventful and he was discharged 6 days after the
intervention.
Comment
Primary pulmonary artery sarcoma is a very rare tumor
with only a few hundred cases having been reported in
the literature [1]. Without surgery the median survival
time is 1.5 month. However, surgery can potentially
prolong survival time to 10 months [1]. Eighteen months
after the first surgical intervention this patient had a
tumor recurrence leading to right ventricle outflow ob-
struction with severe circulatory impairment develop. In
the absence of a surgical option, an interventional ap-
proach was conceptualized. In this patient there was
specific concern that complete right ventricular outflow
obstruction during balloon inflation and stent release
might result in complete cardiac failure. This led us to
select ECC to support systemic and pulmonary circula-
tion during the stent procedure. In addition, transient
cardiac arrest was induced to avoid any cardiac distur-
bance during stent release. Moreover, avoidance of a
mediastinal mass syndrome was achieved by deliberately
preserving the patients ability to breathe spontaneously.
We believed that general anesthesia and mechanical
ventilation might have the potential to obstruct our
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
CASE REPORT ZIMPFER ET AL 747
ENDOVASCULAR STENT-GRAFT TREATMENT
patients airway or pulmonary artery by collapsing tumor
masses. During the whole procedure the patient was only
slightly sedated, and he tolerated the procedure well and
felt comfortable. We have found only one comparable
case in the literature [2]. To reduce an increase in right
ventricular afterload these colleagues also established
percutaneous cardiopulmonary support. However they
performed the complete procedure under general
anesthesia.
We believe that this approach is unique. With the
combination of preserved spontaneous breathing, ECC
and temporary cardiac arrest, balloon inflation and stent
release was safe, yet the technical efforts and expenses
may cause controversial viewpoints. However, in a pa-
tient whose oxygenation was dependent on only two
lobes of a single lung combined with circulatory failure
we saw the medical and surgical needs of the patient
most safely met with the use of ECC under local anes-
thesia combined with light sedation.
In selected patients this approach is a safe technique
with surprisingly high patient comfort and is an effective
FEATURE ARTICLES
alternative to techniques implementing general
anesthesia.
References
1. Anderson MB, Kriett JM, Kapelanski DP, Tarazi R, Jamieson
SW. Primary pulmonary artery sarcoma: a report of six cases.
Ann Thorac Surg 1995;59:148790.
2. Asato Y, Amemiya R, Kiyoshima M, Shioyama Y, Asato M.
Pulmonary artery stenting for recurrent lung cancer after left
pneumonectomy. Ann Thorac Surg 2002;73:1962 4.
Treatment of Acute Type A
Dissection by Percutaneous
Endovascular Stent-Graft
Placement
Daniel Zimpfer, MD, Martin Czerny, MD,
Joachim Kettenbach, MD, Maria Schoder, MD,
Ernst Wolner, MD, Johannes Lammer, MD, and
Michael Grimm, MD
Departments of Cardiothoracic Surgery and Interventional
Radiology, University of Vienna Medical School, Vienna,
Austria
Acute type A dissections are a life threatening condition
requiring immediate surgical intervention to avoid aortic
rupture or pericardial tamponade. Success of surgical
intervention is markedly limited in those patients with
advanced age, neurological deficits, and multiple co-
morbidities at the time of treatment. We report the
successful endovascular stent-graft treatment in a patient
suffering from an acute type A dissection. Due to the
Accepted for publication Nov 22, 2005.
Address correspondence to Dr Zimpfer, Waehringer Guertel 18-20, Vi-
enna, A-1090 Austria; e-mail: daniel.zimpfer@meduniwien.ac.at.
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2005.11.066
 748 CASE REPORT ZIMPFER ET AL Ann Thorac Surg
ENDOVASCULAR STENT-GRAFT TREATMENT 2006;82:7479
FEATURE ARTICLES

Fig 1. Oblique sagittal view of a computed tomographic scan at the

time of diagnosis.

presence of multiple comorbidities the patient was con-

sidered too high risk for surgical treatment.
(Ann Thorac Surg 2006;82:7479)
2006 by The Society of Thoracic Surgeons

E ndovascular stent-graft treatment has emerged as an

alternative treatment option for various diseases of the
descending aorta including aortic type B dissections and

Fig 3. Completion computed tomographic scans. (A) Oblique sagittal

view. (B) Volume-rendered view.

penetrating ulcers. So far, percutaneous endovascular

Fig 2. Digital subtraction completion angiography after stent-graft
implantation.
stent-graft treatment of ascending aortic disease was only
performed in patients with subacute type A dissections and
penetrating ulcers. We report the successful percutaneous
endovascular stent-graft treatment of an acute aortic type A
dissection as the primary and sole treatment of a patient.
Ann Thorac Surg
2006;82:7479
An 84-year-old man was admitted to our emergency
department due to the onset of severe chest pain (6
hours previously). At the time of admission the patient
had paraplegia develop without any signs of central
nervous damage. Computed tomographic scan re-
vealed an acute aortic type A dissection with an entry
tear in the mid portion of the ascending aorta (Fig 1).
After intensive care treatment and steroid bolus ther-
apy, paraplegia completely dissolved [1]. Due to the
patients advanced age, the development of intermit-
tent paraplegia, and the presence of several co-
morbidities (ie, diabetes, history of cerebrovascular
and peripheral vascular disease, and chronic renal
insufficiency), we refused to perform open surgery.
Therefore the patient was presented with the option of
stent-graft treatment. The patient agreed to undergo
percutaneous stent-graft treatment through written
and informed consent.
A custom made stent-graft fitting the dimension of
the ascending aorta (from the sinotubular junction to
the brachiocephalic trunk) was tailored. As soon as the
costume made stent-graft was available, endovascular
treatment was performed.
With the patient under general anesthesia, a custom
made covered stent (Jotec, Hechingen, Germany) 46/85
mm was advanced into the ascending aorta through
the right common femoral artery. Before deploying the
stent-graft, the patient was paced to 180 bpm using a
temporary ventricular pacemaker that was placed in
the right subclavian vein. This was done to decrease
cardiac output and consecutively minimize the risk of
dislodging the stent-graft while deployment was un-
dertaken. Thereafter the stent-graft was deployed dis-
tal to the coronary arteries (controlled by transesoph-
ageal echocardiography) and proximal to the
brachiocephalic trunk. Completion angiography after
stent-graft deployment revealed regular perfusion of
the coronary arteries, complete exclusion of the dissec-
tion, as well as regular perfusion of the supra-aortic
vessels (Fig 2). Aortic valve competence was confirmed
by transesophageal echocardiography.
The patient was extubated immediately after the
procedure, returned to the regular ward on postoper-
ative day 1, and was discharged 7 days after stent-graft
placement. Completion computed tomographic scans
at hospital discharge and 1 month after stent-graft
placement revealed stable position of the stent-graft in
the ascending aorta, regular perfusion of the true
lumen, and aneurismal sac shrinkage (Figs 3A, 3B).
Comment
In patients with advanced age and multiple comorbidi-
ties, surgical treatment of acute aortic type A dissec-
CASE REPORT ZIMPFER ET AL 749
ENDOVASCULAR STENT-GRAFT TREATMENT
tions is limited by a high perioperative mortality [2].
Endovascular treatment of descending aortic disease
has developed as an accepted treatment alternative
due to less invasiveness in these patients [3]. Endovas-
cular stent-graft treatment of aortic type A dissection
in the nonacute setting, as well as treatment of pene-
trating ulcers has been reported in the past [4, 5]. We
report on successful percutaneous treatment of an
acute Stanford type A dissection with a covered stent
graft as primary and sole treatment.
The main benefit of this approach is its minimally
invasive fashion, avoiding sternotomy as well as circu-
latory arrest. However, endovascular treatment bears
the risk of catheter intervention-associated complica-
tions. Endovascular treatment of type A dissections
further bears the risk of compromising the aortic valve,
the coronary arteries, and the supraaortic vessels due
to the special anatomy of the ascending aorta. In
addition this treatment can only be offered to those
patients with uncompromised aortic valve function (ie,
FEATURE ARTICLES
no higher grade insufficiency) and an entry tear well
above the coronary ostia in order to obtain a sufficient
landing zone. Furthermore, the long-term durability of
this approach is uncertain. Nevertheless this approach
may add as an alternative treatment option in patients
with multiple comorbidities and high surgical risk. A
prerequisite before offering this approach to a broader
patient population is exact knowledge on the needed
stent-graft dimensions as there will be not enough time
to tailor make a stent-graft in the majority of patients
with acute type A dissections. Broader application of
this technique will reveal its safety and efficacy, espe-
cially with regard to long-term outcome.
In conclusion, endovascular treatment of type A
dissections is a promising option for those patients not
suitable for conventional surgical repair and may add
to the weaponry of cardiothoracic surgeons.
References
1. No authors listed. Steroids after spinal cord injury. Lancet
1990;4;336(8710):279-80.
2. Ehrlich MP, Schillinger M, Grabenwoger M, et al. Predictors
of adverse outcome and transient neurological dysfunction
following surgical treatment of acute type A dissections.
Circulation 2003;108(Suppl 1):II318 23.
3. Grabenwoger M, Fleck T, Czerny M, et al. Endovascular stent graft
placement in patients with acute thoracic aortic syndromes. Eur
J Cardiothorac Surg 2003;23(5):78893; discussion 793.
4. Zhang H, Li M, Jin W, Wang Z. Endoluminal and surgical
treatment for the management of Stanford type A aortic
dissection. Eur J Cardiothorac Surg 2004;26(4):8579.
5. Ihnken K, Sze D, Dake MD, et al. Successful treatment of a
Stanford type A dissection by percutaneous placement of a
covered stent graft in the ascending aorta. J Thorac Cardio-
vasc Surg 2004;127(6):1808 10.