Abstract
A 56-year-old man with sudden onset chest pain, absent right lower limb pulses and ECG changes suggestive of inferior ST elevation MI underwent coronary angiogram through the right radial artery with a view to primary percutaneous coronary intervention (PCI). The left coronary angiogram demonstrated severe proximal stenotic disease in the left anterior descending and circumflex coronary arteries, but the right coronary artery could not be selectively cannulated. An ascending aortogram to visualise the right coronary artery not only failed to demonstrate it, but revealed, instead, a dissection flap in the ascending aorta, arch and descending thoracic aorta, with moderately severe aortic regurgitation. At operation, the patient was found to have an acute dissection of the ascending aorta, arch and descending aorta with an entry tear in the descending aorta below the left subclavian artery origin. Triple coronary artery bypass grafting with re-suspension of the aortic valve, supracoronary replacement of the ascending aorta and hemiarch and transaortic repair of the descending aortic tear was performed. The patient made an uncomplicated recovery, with the re-appearance of right limb pulses. A postoperative magnetic resonance (MR) scan revealed complete thrombosis of the false channel in the residual arch and a considerably shrunken false channel in the descending aorta and no aortic regurgitation.
Retrograde dissection of the ascending aorta from the descending aorta has been reported infrequently in the past. We believe the scale of the problem has been underestimated because of the failure to adopt open distal anastomosis routinely in the past and, hence, failure to inspect the arch and the descending aorta routinely, particularly when the intimal tear was not identified in the ascending aorta. Retrograde dissection of the ascending aorta from an intimal tear in the descending aorta, when identified as such, has been managed, either on the principle of exclusion of the tear in the descending aorta by various elephant trunk procedures and their variants or, alternatively, on the principle of excision of the tear by extended one-stage aortic replacement, usually combined with an elephant trunk procedure. Neither of these procedures is widely adopted, owing to procedural, institutional and outcome considerations. We describe a transaortic repair of the intimal tear in the descending aorta with supracoronary interposition graft replacement of the ascending aorta and hemiarch with excellent clinical and radiological result. We also review the diagnostic and therapeutic approaches to this incompletely understood lethal disease.