698 CASE REPORT KıZıLTAN ET AL Ann Thorac SurgINTIMAL PROLAPSE AORTIC DISSECTION 2014;97:698–700

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Comment

As the role of TAVR in the treatment of severe-criticalAS patients with significant co-morbidities grows,alternative access approaches in patients with inade-quate femoral access are being performed withincreasing frequency. Alternative access includestransapical, direct aortic (TAo), and subclavian/carotidartery approaches, each with its own advantages anddisadvantages. In this patient, iliofemoral access wasnot possible. Because of the need for concomitantTAVR and TEVAR, both transapical and TAo ap-proaches were considered. Our group decided thatTAo offered the ideal benefit of performing TAVR firstto optimize hemodynamics, before placement ofTEVAR. The disadvantage of the transapical approachwas that it would require the GoreTAG endoprosthesisto either cross a severely stenotic aortic valve, creatinga risk for hemodynamic instability, or the freshlydeployed Sapien prosthesis with the attendant risk forvalve damage. In addition, because of the patient’shistory of COPD, we believed that a left thoracotomywould be poorly tolerated from a pulmonarystandpoint.

A specific introducer sheath for TAo access is beingdesigned; however, this was not available at the timeof operation. The only commercially available TAVRplatform was the Edwards transfemoral RF3 system.To optimize our procedure via the TAo approach, theRF3 sheath was cut short and adjusted to the ideallength required for device delivery. Given the largediameter of the 24-French Edwards RF3 sheath, ante-grade TEVAR and deployment of the two GoreTAGstent grafts was possible without exchanging for anew introducer sheath. Radiopaque markers were nolonger present because the distal tip of the sheath wasremoved after cutting the sheath. Therefore, for easeof visualization, the outside of the RF3 sheath wasmeasured and marked at 1-cm increments. Owing tothe lack of ascending aortic working space (in order toallow room for the balloon expansion), only 2 cm ofthe sheath was placed within the ascending aorta. Atour institution, this approach using a presized andpremarked RF3 sheath has been highly successful foralternative access TAVR.

The feasibility of this procedure in an 88-year-old pa-tient with severe comorbid disease attests to the utility ofthe TAo approach for hybrid endovascular operations.However, success requires a comprehensive heart teamin the setting of a hybrid operating room suite withsophisticated imaging.

Accepted for publication May 2, 2013.

Address correspondence to Dr Kızıltan, Hekimk€oy Sitesi D-5, No. 108Sarıcam, Adana, Turkey 01000; e-mail: htkiziltan@yahoo.com.

Video 1 can be viewed in the online version of thisarticle [http://dx.doi.org/10.1016/j.athoracsur.2013.05.110] on http://www.annalsthoracicsurgery.org.

References

1. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valveimplantation for aortic stenosis in patients who cannot un-dergo surgery. N Engl J Med 2010;363:1597–607.

2. Wiegerinck EM, Cocchieri R, Baan J Jr, de Mol BA. Hybridcoronary artery bypass grafting and transaortic transcatheteraortic valve implantation. J Thorac Cardiovasc Surg 2013;145:600–2.

� 2014 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

3. Bruschi G, de Marco F, Botta L, et al. Direct aortic access fortranscatheter self-expanding aortic bioprosthetic valves im-plantation. Ann Thorac Surg 2012;94:497–503.

Intimal Intussusception in AorticDissection and CoexistingCoronary Artery DiseaseH. Tarık Kızıltan, MD, M€unir Tıras, MD, Aslı _Idem, MD,Rahime Camsarı, MD, Sebahattin Toktas, MD, andAbdi Bozkurt, MD

Departments of Cardiovascular Surgery, Cardiology,Anesthesiology and Reanimation, and Radiology, €Ozel AdanaHastanesi; and Department of Cardiology, G€uney AdanaHastanesi, Adana, Turkey

Intimal tear is rarely circumferential in aortic dissection.In such an instance, intimal intussusception may occur.This exposes the patient to the additional risk of severeaortic regurgitation, blockage of the left main coronaryartery ostium, or both in proximal intimal intussuscep-tion in ascending aortic dissection. Here we present a61-year-old patient with ascending aortic dissection,aortic regurgitation caused by an intussuscepted proximalintimal flap, and coexisting coronary artery disease. Thepresenting symptoms and electrocardiographic findingssimulated an acute coronary syndrome. Among otherdiagnostic measures, only transesophageal echocardiog-raphy clearly defined the pathologic condition. The pa-tient underwent a successful aortic root replacement andcoronary artery bypass grafting.

(Ann Thorac Surg 2014;97:698–700)� 2014 by The Society of Thoracic Surgeons

roximal intimal intussusception in the context of

Pascending aortic dissection is rare [1]; yet, it maycause severe aortic regurgitation by disturbing thecoaptation of the aortic leaflets [2, 3], impairment of cor-onary blood flow by left main coronary artery occlusion[3, 4], or both. These occurrences may further complicatethe diagnostic and operative management of aorticdissection. We present a patient who had ascending aorticdissection, coronary artery disease, and aortic regurgita-tion caused by intussuscepted intimal flap.

A 61-year-oldheavy smokerwithnohistoryofhypertensionwas admitted to our emergency room. Before admission, hehad lost consciousness for half an hour after experiencing

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Fig 1. Aortography showing severe aortic regurgitation, proximalcircumflex artery occlusion (short arrow), normal left anteriordescending artery, intimal flap (white arrow), and an appearancemimicking a penetrating atherosclerotic ulcer (long arrow).

Fig 2. Computed tomographic scan showing no intimal flap or atrue-false lumen formation and otherwise normal aorta with someartifacts.

699Ann Thorac Surg CASE REPORT KIZILTAN ET AL2014;97:698–700 INTIMAL PROLAPSE AORTIC DISSECTION

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acute chest pain. On admission, he had minimal pain, hewas neurologically normal, his peripheral pulses werepalpable, and a grade 3 diastolic murmur was heard in hischest. His blood pressure was 120/80 mm Hg, and an elec-trocardiogram showed inferior myocardial infarction inaddition to ST depression and T-wave inversion in leads V5

to V6. Because of the risk of acute coronary syndrome,emergency coronary angiography was performed. On theangiogram, the right coronary artery was 60% stenotic.Selective catheter insertion was not possible into the leftmain coronary artery (LMCA) ostium; therefore, the LMCAand its branches were visualized with the help of aortog-raphy, which revealed severe aortic regurgitation, total oc-clusion of the proximal circumflex artery, and a normal leftanterior descending artery (Fig 1). In addition, aortographyshowed pictures of intimal disturbance above the aorticleaflets, which would be likely either for a flap of dissectedaortic segments or for a penetrating atherosclerotic ulcer[5] (Fig 1). Computed tomography (CT) (Siemens,Somatom Sprit, China) showed neither an intimal flap nora true-false lumen formation but did reveal a mostlynormal proximal ascending aorta with some linear artifacts(Fig 2). On the CT scan, the aortic diameter was 4 cm atthe aortic valve level and 4.5 cm at the sinuses of Valsalva.The troponin level was within normal range. We decidedon an emergency operation to address the still unclearacute aortic pathologic condition and the coexistingcoronary artery disease. Transthoracic echocardiographyrevealed aortic regurgitation but no pathologic conditionof the ascending aorta. Preoperative transesophagealechocardiography (TEE) (General Electric) to clarifythe pathologic condition of the aorta revealed aorticregurgitation and a circumferential intimal flap consistentwith aortic dissection (Fig 3). On TEE, the intimal flap hada pattern of action exactly like an aortic valve, and it wouldhave been difficult even for our experienced cardiologistto differentiate it from the aortic valve, which was indeedlocated beneath the flap (Fig 3) (Video 1). During theprocedure, we found that aortic dissection confined to theascending aorta only (DeBakey type II). The intimal tearwas 4 cm above the valve, and it was circumferential,which disrupted the proximal and distal parts completely.There was only a small (2-mm) rim of distal intimaldissection. The aorta surrounding the coronary ostia wasextensively dissected. The aortic leaflets were anatomicallynormal.

The patient underwent aortic root replacement (button-Bentall), with use of a composite graft (Carboseal, Car-bomedics, Italy), and coronary bypass grafts to the rightand obtuse marginal arteries. The operation was un-eventful, and the patient was discharged on the sixthpostoperative day after a routine recovery.

Intimal (intimo-intimal) intussusception was firstdescribed by Hufnagel and Conrad [6], and it applies toprolapse either of the distal intimal tube into the aorticarch [7] or of the proximal intimal tube into the leftventricle [8] when the intimal tear is circumferential inascending aortic dissection. In proximal intimalintussusception, the intimal tube propagated by thediastolic aortic flow prolapses into the left ventricle and

interferes with aortic valve function, causing aorticregurgitation [2, 3]. It is also reported that blockage ofLMCA flow by the intimal layer may occur, creatingcoronary ischemia [3, 4], with elevated markers ofmyocardial injury [4] in the absence of coronary arterydisease. Because this is one of the most lethal forms ofaortic dissection, making surgical intervention urgent, atimely diagnosis—which is difficult in most cases [4]—isnecessary in obtaining a satisfactory clinical outcome.As is a universal experience in similar cases, a diag-

nostic difficulty occurred in our case. Chest pain asso-ciated with electrocardiographic changes promptedemergency coronary angiography, during which theinability to cannulate the LMCA ostium necessitatedaortography to visualize the LMCA and its branches. Inour view, aortography clearly gave important information

Fig 3. Transesophageal echocardiogramduring (A) systole and (B) diastole showingascending aorta, aortic valve and proximalintimal flap. (Av ¼ aortic valve; F ¼ prox-imal intimal flap.)

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700 CASE REPORT KUMPATI ET AL Ann Thorac SurgENDOVASCULAR REPAIR OF ASCENDING AORTA 2014;97:700–3

in the diagnosis of aortic dissection, but it was not accu-rate enough to differentiate it from a penetratingatherosclerotic ulcer, which would have different clinicalimplications as one of the variants of aortic dissection [5].As has been reported previously [2], our findings in CTwere not conclusive for aortic dissection because thescan lacked the demonstration of true and false lumensseparated by an intimal flap. Logically, this was relatedto the short aortic segment involved in the dissectionprocess. We found it to be in the best interest of thepatient to define the aortic pathologic condition beforegoing into the operating room, and therefore performedthe TEE preoperatively.

Inasmuch as the aortic valve was anatomically normal,one can intuitively argue whether a supracoronary as-cending aortic replacement or a valve-sparing ascendingaortic replacement could have, or should have, beenperformed. We believe that because the aortic circlearound the coronary ostia was extensively involved in thedissection process, a supracoronary ascending aorticreplacement would have been a less than satisfactoryprocedure in that regard. Instead, we preferred to sepa-rate both coronary buttons from their Valsalva sinusessurgically, then fix the surrounding dissected layers using4-0 Prolene and a strip of Teflon while sewing them backto a firm tissue such as a Dacron graft. Obviously, thatdecision does not prevent one from performing a valve-sparing procedure, which any team highly experiencedin these procedures might have considered in such anemergency situation.

Accepted for publication May 15, 2013.

Address correspondence to Dr Kumpati, University of Utah, Division ofCardiothoracic Surgery, 30 N 1900 E, #3C-127, Salt Lake City, UT 84132;e-mail: ganesh.kumpati@hsc.utah.edu.

Comment

Ascending aortic dissection with aortic regurgitationcaused by intussusception of the proximal intimal flapand accompanying coronary artery disease can be treatedwith excellent surgical outcome, given the emergencypresentation and life-threatening complexity inherent inthis pathologic condition. Our experience confirms that inpatients with ascending aortic dissection, TEE stands asan invaluable diagnostic utility in defining proximalintimal flap intussusception beyond a continuum ofdiagnostic facilities including aortography, CT, andtransthoracic echocardiography.

� 2014 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

References

1. Yavuz S, Elhan K, Eris C, Tugrul Goncu M. Intimo-intimalintussusception: a rare clinical form of aortic dissection. Eur JCardiothorac Surg 2003;23:850–1.

2. Yamabi H, _Imanaka K, Sato H, Matsuoka T. Extremely local-ized aortic dissection and intussusception of the intimal flapinto the left ventricle. Ann Thorac Cardiovasc Surg 2011;17:431–3.

3. Yang EH, Kwon MH, Mahajan A, et al. Circumferential type Aaortic dissection and intimal intussusception of the aortacausing severe aortic regurgitation and obstruction of the leftmain coronary artery. Echocardiography 2013;30:e81–4.

4. Lajevardi SS, Sian K, Ward M, Marshman D. Circumferentialintimal tear in type A aortic dissection with intimo-intimalintussusception into the left ventricle and left main coronaryartery occlusion. J Thorac Cardiovasc Surg 2012;144:e21–3.

5. Coady MA, Rizzo JA, Elefteriades JA. Pathologic variants ofthoracic aortic dissections: penetrating atherosclerotic ulcersand intramural hematomas. Cardiol Clin 1999;17:637–57.

6. Hufnagel CA, Conrad PW. Intimo-intimal intussusception indissecting aneurysms. Am J Surg 1962;103:727–31.

7. Lijoi A, Scarano F, Canale C, et al. Circumferential dissection ofthe ascending aorta with intimal intussusception: case reportand review of the literature. Tex Heart Inst J 1994;21:166–9.

8. Come PC, Bivas NK, Sacks B, Thurer BL, Weintraub RM,Axelrod P. Unusual echocardiographic finding in aorticdissection: diastolic prolapse of intimal flap into left ventricle.Am Heart J 1984;107:790–2.

Endovascular Repair of AcuteAscending Aortic Disruption viathe Right Axillary ArteryGanesh S. Kumpati, MD, Robert Gray, MD,Amit Patel, MD, and David A. Bull, MD

Divisions of Cardiothoracic Surgery and Pediatric Cardiology,University of Utah, Salt Lake City, Utah

Endovascular repair of emergent syndromes involving theascending aorta is uncommon. We describe an acutedisruption of the ascending aorta during stenting of thepulmonary artery, resulting in an acute aortopulmonary

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