The Department of Cardiology at PGIMER, Chandigarh achieved another milestone by successfully undertaking the first ever endovascular (TEVAR) repair for aortic dissection at the premier most health care institute of the region. The sugery was performed by a team of doctors lead by Dr Shiv Bagga who is an assistant professor in the department. The patient a 49 year old male and resident of Amritsar presented to the emergency department of the institute with refractory back pain. On evaluation he was found to have an impending rupture of a dissecting aneurysm involving the descending thoracic aorta. According to Dr Bagga aortic dissections are the most common aortic emergencies which occur following separation of the layers constituting the wall of the aorta which is the main outflow artery from the heart. As can be imagined from the importance of this blood vessel, aortic dissections are associated with a high mortality rate. The most common risk factor is uncontrolled hypertension besides rare connective tissue disorders.
The patient suffered from the dissection involving the descending thoracic aorta with extension into the abdominal aorta as well. The usual treatment for such group of patients is optimal medical therapy with aggressive control of hypertension. However, complicated acute aortic dissections as in this patient requires urgent or emergent intervention by an open surgical or endovascular approach, as medical therapy alone carries a very high mortality. The major challenge in the case involved the decision regarding choosing the treatment modality. According to Dr Bagga Open surgery in the acute setting carries a significant operative mortality and is associated with a high morbidity. Endovascular repair is rapidly becoming a preferred approach by many centers for treatment of these distal dissections. Immediate endovascular repair avoids the potential of high-risk surgical procedures, lowers postoperative complications which shortens hospital stay.
After thorough discussion with the surgical team it was decided to proceed with the endovascular repair. According to Dr Bagga assessment of aortic dissection anatomy (tortuosity and involvement of branch vessels), adequate peripheral access, and assessment for extent of coverage necessary are important for technical success of this procedure. The procedure requires a vascular surgical assistance which was ably provided by the cardiothoracic vascular surgical team led by Dr Anand Mishra, an assistant professor in the CTVS department.
According to the treating team, all patients with aortic dissection should be considered at high risk of its late sequelae. Neither open nor endovascular repair can reverse the natural history of the disease, unless the entire extent of the dissection is excluded utilizing complex hybrid procedures. These hybrid procedures seems promising but long term data of these procedures is not known. Intensive lifelong surveillance is mandatory for all patients with treated or untreated aortic dissection.
According to Dr Bagga, there is an increasing need to create awareness among people and even non cardiologist physicians regarding the importance of these life-threatening aortic pathologies. Misdiagnosis of these pathologies usually because of confusion with myocardial ischemia often leads to improper treatment and untimely deaths. Similar to the success for expediting the care of patients with acute coronary syndromes, similar standards should be evolved for these life threatening aortic emergencies.