Title: ACS with saccular aortic arch aneurysm

Biography:

Dr. Raed  Nayef  Zalloum is working as a Cardiovascular Specialist at Bezmialem Foundation University, Turkey. He is a Head of the vascular surgery department in Jazan armed forces hospital, Saudi Arabia.

Abstract

A 73 years old female patient was referred to our hospital due to a chest and back pain,the primary diagnosis in the refering hospital was assumed as a ruptured aortic arch aneurysm. The patient was admitted to our cardiovascular intensive care unit and we started to do our investigations. 10 years ago, the patient had a history of CABG X 4 and advanced COPD disease, an increased opacity on the left side of the PA chest Xray was seen and thorax abdomin CTA was planned.A giant saccular aneurysm, 12 X 10 cm in size, originating at the distal aortic arch including the left subclavian artery was detected on the CTA without signs of rupturing. At the same time, a 7 X 6 cm abdominal aortic aneurysm was seen at the infrarenal level. We found out the troponin level was high and we submit our diagnosis as ACS. In the previous surgery reports of the patient, it was understood that LIMA was used for LAD bypass.The flow in LÄ°MA was severe decreased in the coronary angiography ,It was thought that the existing ACS was formed after the compression of the LIMA by the giant saccular aneurysm. Coronary revascularization was achieved with PTCA to the native LAD of the patient and clopidogrel 75mg OD started. The patient was followed up in CVS ICU until the decision of the next surgical procedure. In the follow-up after the procedure, it was observed that the troponin value decreased and the patient's pain completely disappeared. There were no complications after the procedure. After few days under clopidogrel the patient was taken to OR Arcus Aort Debranching was done with 7 X 14 mm collagen coated Hemagard(knitted) Y vascular graft;the proximal anastomosis was from the Asendan Aort while the distal anastomosis were right to Brachiocephalic trunk and left to the Left Common Carotid artery. At the end of the operation patient transfered to the Angiographic unit and with seldinger technique TEVAR graft was inserted successfully started from zone 0 in the Arcus aorta as proximal landing zone.The left subclavian artery was coiled from the ostium to forbid the retrograt flow inside the aneurysm sac.Patient was taken to the ICU unit for postoperative care.

In the first postoperative day ischemic changes was noticed on the left upper extremity Urgent artery duplex was done showing no thrombosis but the flow was insufficient.We took the patient again to OR and Supraclavicular Left Common Carotid Subclavian bypass was done with 6mm collagen knitted vascular graft.The patient was taken again to the ICU unit. Postoperatively the ischemia in the left hand improved,cardiac situation was acceptabile EF 55% controlled with ECHO,there was no pericardial tamponade,the inotrop drugs dosage were decreased,no hemopneumothorax was seen but unfortunately postoperative 6th day the patient died because of infective sepsis.