Comment
Rupture at the site of KD has been previously reported in the
literature. Austin et al., reported 19% incidence of rupture at the
site of KD with 100% mortality.2
Surgical approach in a patient with aortic tear/rupture or acute
dissection is centered on excluding the site of tear/rupture from the
circulation to prevent exsanguination.
Open repair for type A IMH and proximal DTA rupture requires median
sternotomy and AAo, total arch and proximal DTA replacement. Other
option would be to do a two-stage procedure with total arch replacement
and placement of an elephant trunk. However, two stage elephant trunk
carries a significant interval mortality due to aortic cause, and also
significant number of patients do not undergo second stage thoracotomy
for completion.3 Conventional elephant trunk also does
not address the DTA rupture immediately.
The various options for hybrid repair in this setting include total arch
replacement and elephant trunk placement followed by endovascular
completion,4 total arch replacement and placement of a
frozen elephant trunk (FET),4 subclavian artery bypass
followed by zone 2 TEVAR and coil embolization of
SCA,4 or a single stage total aortic arch debranching
and TEVAR with zone 0 landing.5 Totally endovascular
exclusion of ruptured KD with SCA stenting has also been
demonstrated.6
Pathology of the AAo and AoA in our patient mandated AAo and arch
replacement. Lack of landing zone between carotid and subclavian ostium
and large size of the aortic arch precluded the option of retrograde
TEVAR with zone 2 placement. We chose the option of FET as it can be
safely deployed in this narrow area. Stent graft in DTA also provides a
more stable landing zone for retrograde TEVAR compared to the standard
elephant trunk.7
We ligated the origin of both the subclavian arteries as it has been
shown to be the source of type II endoleak.(4,8)However, we had type Ia endoleak after completion of FET and this was
remedied with more extensive zone 0 landing in the ascending aortic
graft. Initial performance of subclavian-carotid bypass and carotid
debranching gave us flexibility to better exclude the site of tear and
fix type Ia endoleak with retrograde TEVAR.