Type A Aortic Dissection Complicated with Refractory Hypertension after Surgical Repair

Resident(s): Travis Howard, MD

Attending(s): Sanjay Misra, MD, Haraldur Bjarnason, MD, and Reza Rajebi, MD

Program/Dept(s): Vascular and Interventional Radiology

CHIEF COMPLAINT & HPI

Chief Complaint and/or reason for consultation Complaints of recurrent dizziness at follow up appointments

History of Present Illness Fifty-six year old man with history of Type A Aortic Dissection. He is one month removed from ascending aortic and hemi-arch replacement with re-suspension of the aortic valve.

RELEVANT HISTORY

Past Medical History Hyperlipidemia, Hypertension, DM II, CAD s/p stent placement, Obesity Past Surgical History Stanford type A aortic dissection repair Nov. 13, 2014 Family & Social History Family history non-contributory 40 pack/year tobacco use history. Quit in 2007.

Review of Systems Other than dizziness, review of systems was negative Medications ASA, Clopidogrel, Statin, Hydralazine, Labetalol, Amlodipine, Isosorbide mononitrate,

Nitroglycerin

Allergies NKA

DIAGNOSTIC WORKUP

Physical Exam Systolic blood pressures were elevated at 180-200mmHg. Otherwise, unremarkable.

Laboratory Data Normal renal function No electrolyte abnormalities

Non-Invasive Imaging

Collage of images from a CAP CT angiogram demonstrates that the aortic dissection flap extends into the aortic arch. At the level of the renal arteries, the right renal artery is supplied by the compressed true lumen. The left renal artery is supplied by the false lumen.

DIAGNOSTIC WORKUP: NON-INVASIVE IMAGING

DIAGNOSTIC WORKUP: NON-INVASIVE IMAGINGDoppler ultrasound at the origin of the right renal artery demonstrates severely diminished renal artery velocity and a tardus parvus waveform.

Doppler ultrasound at the level of the segmental right renal arteries demonstrates significantly dampened waveforms.

Doppler evaluation of the left renal artery demonstrates velocities at the upper end of normal.

DIAGNOSTIC WORKUP: NON-INVASIVE IMAGING

DIAGNOSIS

Hemodynamically significant stenosis of the right renal artery by the aortic dissection flap

DSA: Catheterization of the true lumen with contrast filling the right renal artery.

Mean arterial blood pressure within the true lumen measures 20mmHg.

Right renal artery

Contrast filling the true lumen

INTERVENTION

Link to Video

DSA: Catheterization of the false lumen with contrast filling the left renal artery.

Arterial blood pressure within the false lumen measures 95 mmHg.

INTERVENTION

Link to Video

A Pioneer device was advanced from the right common femoral artery and deployed towards the aortic dissection flap into the false lumen.

Pioneer Device

INTERVENTION