A 71-year-old male patient, surnamed Liu, was diagnosed with coronary heart disease in a local hospital 8 years ago and implanted with 3 stent grafts. He presented with chest tightness and shortness of breath in May, and chest pain and discomfort, intermittent chest tightness and shortness of breath for the recent 1 week. He was diagnosed with acute non-ST-segment elevation myocardial infarction in a local hospital. Coronary angiography prompted three-vessel coronary artery disease complicated with severe left main bifurcation disease. Due to the high surgical risk and difficulty, the patient was transferred to Department of Cardiology of the First Affiliated Hospital of Xi’an Jiaotong University (XJTU) on June 9, 2021.
At 20: 00 pmon June 9, the patient was transferred to Department of Cardiology of our hospital. He developed the onset of acute left heart failure in a critical condition, and he was at a risk of sudden death, cardiogenic shock and myocardial infarction,etc. After explicit preoperative consultation, it was determined to perform intra-aortic balloon pump (IABP)-assisted interventional therapy for the left main coronary artery disease to rescue the patient from the critical condition. When reviewing the clinical data, Chief Physician Guo Ning and Attending Physician Luo Yongbai found that chest CT scan in a local hospital was indicative of the possibility of thoracic aortic ulcer, and then emergency CTA of the thoracic aorta showed the sign of aortic arch sac-like bulge, which was considered as the penetrating aortic ulcer. Thoracic aortic ulcer is a life-threatening condition. Once the ulcer penetrates the aortic wall, it may cause critical issues, such as aortic dissection and hemorrhagic shock,etc. Moreover, aortic ulcer is contraindication of IABP, which increases the risk of coronary stent grafting.
Aortic ulcer is not only a contraindication of IABP and intensified antithrombotic therapy in Department of Cardiology, but also increases the difficulty and risk of coronary interventional therapy, which might endanger the patient's life at any time. The team led by Chief Physician Guo Ning repeatedly evaluated the patient's condition, and specially invited Chief Physician Tian Hongyan and Deputy Chief Physician Zhang Junbo from Department of Peripheral Vessels to deliver joint consultation. Eventually, the regime of "one-stage vascular surgery" was determined. First, aortic intracavitary isolation was performed by Department of Peripheral Vessels, and then IABP-assisted coronary interventional therapy was completed by Department of Cardiology, and ECMO might be delivered by Department of Cardiovascular Surgery if necessary.
At 8:10 am on June 11, Chief Physician Tian Hongyan and Deputy Chief Physician Zhang Junbo first performed aortic endovascular isolation. Subsequently, Chief Physician Guo Ning, Chief Physician Luo Yongbai and Attending Physician Zhang Yong successfully implanted IABP and completed interventional treatment of the complex left main lesions. Intraoperatively, vital signs of the patient were stable. Postoperative angiography results were satisfactory, detecting that the severe stenosis of the whole left coronary artery was relieved, and the blood flow was restored to normal. The patient was transferred to ward after successful surgery for over 3 hours.
The success of “one-stage vascular surgery” not only resolves two life-threatening conditions, relieves surgical pain of repeated surgeries, but also guarantees the safety during the perioperative period. According to literature review, this is first case of "one-stage vascular surgery" for a patient with penetrating aortic ulcer complicated with severe coronary heart disease in China.
