The value of transesophageal echocardiography for endovascular graft stenting of the ascending aorta

YPERTENSION, CONGENITAL valvular abnormalities like bicuspid and unicuspid aortic valves, and the Marfan syndrome are important risk factors for the development of intrathoracic aortic aneurysms. 1 In descending aortic aneurysms, endovascular stenting has become an accepted alternative to open repair in high-risk patients with severe comorbidities. 2,3 In this case report, the authors describe a patient with a Stanford type A dissecting ascending aortic aneurysm undergoing endovascular stenting, illustrating the important contribution of transesophageal echocardiography (TEE) during the procedure. CASE REPORT An 87-year-old female patient with a history of hypertension and anxiety disorder was admitted for treatment of an ascending aortic aneurysm diagnosed after an acute episode of chest pain radiating to the back. Normal electrocardiogram and cardiac enzymes ruled out a myocardial infarction. A spiral computed tomography angiogram showed severe atherosclerotic degeneration, extensive intramural hematoma from the aortic root to the level of the celiac axis, and a Stanford type-A dissection of the ascending aorta with the primary intimal tear in the distal ascending aorta. The ascending aorta was dilated to 5-cm diameter including the hematoma, and the presence of fluid in the mediastinum and pericardium suggested a contained rupture. She was admitted to the intensive care unit to achieve blood pressure control with intravenous esmolol and sodium nitroprusside. The following day, she remained hemodynamically stable with overall good end-organ perfusion. The patient refused a surgical intervention but agreed to undergo stent placement. After induction of general anesthesia, a transesophageal echoprobe was placed. The aortic valve appeared to be trileaflet with moderate regurgitation. The diameter was 2.5 cm at the annulus and 3.3 cm at the sinotubular junction. The ascending aorta had a diameter of 4.2 cm with an intramural hematoma on the anterior wall extending to the right coronary artery (Fig 1) and an intimal flap extending to the aortic arch and descending aorta. The mitral and tricuspid valves were normal. Pericardial and bilateral pleural effusions were found, whereas the myocardial contractility was estimated to be within normal limits. The right brachial and femoral arteries were cannulated, and under TEE guidance, using color flow and the angiomode, a guide wire was passed from the brachial artery entry site to the aortic arch and down to the descending aorta (Fig 2), snared, and pulled out through the vascular sheath in the right common femoral artery. An arch aortogram was performed with a pigtail catheter in the ascending aorta to confirm the position of the guide wire in the true lumen. Afterward, a 10 40 mm stent graft was advanced into the ascending aorta over the guide wire and positioned just distal to the coronary arteries. After confirmation of the optimal position of the stent in the ascending aorta with contrast injections, its deployment was monitored with TEE and fluoroscopy (Fig 3). The patency of the right and left main coronary arteries was verified, and the absence of flow in the false lumen was confirmed with TEE (Fig 4). An arch aortogram showed that the dissection was successfully excluded.