A Case of Disseminated Intravascular Coagulation after Thoracic Endovascular Aortic Repair

Abstract

I report a hemorrhagic complication due to disseminated intravascular coagulation after thoracic endovascular aortic repair for a dissecting aortic aneurysm. A 74-year-old man underwent thoracic endovascular aortic repair and carotidcarotid artery bypass to close the primary entry site of the dissecting aortic aneurysm. Postoperatively, he developed a gradually expanding cervical hematoma. Laboratory data showed disseminated intravascular coagulation. He could not extubated until postoperative day 6 because of the risk of airway obstruction. He was treated with transfusion to replenish the coagulation factor. Disseminated intravascular coagulation may occur secondary to thrombus formation in the false lumen after thoracic endovascular aortic repair.Keywords: disseminated intravascular coagulation, aortic aneurysm, blood vessel prosthesis but had not been followed up. Computed tomographic angioglaphy showed a Stanford type B chronic aortic dissection extending from the distal aortic arch to the abdominal aorta, with the false lumen entirely patent (Fig. 1a). The primary entry site was 20 mm distal to the origin of the left subclavian artery (Fig. 1b), and the re-entry site was at the origin of the left renal artery. The maximum diameter of the distal aortic arch was 72 mm, and the diameter of the descending aorta was 65 mm. The celiac axis, superior mesenteric artery and right renal artery originated from the true lumen. Laboratory data showed mild coagulopathy: fibrinogen 262 mg/dl, prothrombin time international normalized ratio 1.39, activated partial thromboplastin time 34.5. Liver function test was within normal limits. It would have been difficult to perform conventional replacement of the descending aorta via left thoracotomy because the patient had been bedridden for a long time and could not even stretch the left arm and could not be placed in the left lateral position due to joint contracture. To avoid the risk associated with conventional open surgery, I decided to perform TEVAR to close the primary entry site.The procedure was performed under general anesthesia using the Zenith TX2 TAA Endovascular Graft (Cook Medical, Bloomington, Ind). To ensure enough length of the healthy aorta at the proximal neck, the stent graft was positioned so that it covered the origins of the left common carotid artery and left subclavian arteries after carotidcarotid artery bypass (Fig. 2a). The left subclavian artery was not revascularized because preoperative magnetic resonance imaging showed communication between the right and left vertical arteries. The origin of the left subclavian artery was embolized with metallic coils to prevent a type 2 endoleak. The primary entry site in the distal aortic arch was covered with the stent graft, and postoperative angiography did not show contrast medium in the false lumen of the thoracic aorta (Fig. 2b). The re-entry site at the origin of the left renal artery was not closed. The operation time was 276 min and no blood transfusion was needed.After surgery, the patient was transfe...

Management of disseminated intravascular coagulation after thoracic endovascular aortic repair of type B aortic dissection: a case report

“…The exact mechanism in this regard has not been elucidated. Most researchers consider that DIC after TEVAR of aortic dissection is secondary to consumptive coagulopathy caused by persistent retrograde flow in the false lumen [ 11 , 12 ]. Identification and preventative substitution therapy for patients at high risk may help to prevent DIC.…”

“…Open surgery may be a radical treatment to correct the hemorrhagic diathesis but is quite invasive [ 13 ]. With rapid advances in endovascular technology, different methods for sealing re-entry tears have emerged [ 2 , 4 , 7 , 12 ]. However, surgical or endovascular intervention may not be suitable for all patients, especially those with high operative risk.…”

Fatal Hemorrhage from Kidney after Endovascular Repair for Chronic Type B Dissection Complicated with Disseminated Intravascular Coagulation

“…Kotani et al reported a case of worsened coagulopathy resulting in a gradually expanding cervical hematoma after TEVAR for primary entry closure of chronic type B dissection. 3) The authors speculated that DIC might occur secondary to thrombus formation in the false lumen after TEVAR. Sasaki et al reported that prothrombin time, platelet count, and fibrinogen levels tended to be normalized by the 7th postoperative day.…”

“…Her blood test results gradually and slightly worsened temporarily, probably due to thrombosis in the false lumen. Her platelet count decreased from 3.9 × 10 4 to 2.2 × 10 4 /mm 3 and her fibrinogen level decreased from 1460 mg/L to 830 mg/L. These values gradually recovered 10 days after abdominal cavity the next day.…”

“…1,2) Additionally, postoperative DIC after thoracic endovascular repair (TEVAR) has been reported. 3) We report a case of fatal hemorrhage from the left kidney, requiring emergent embolization of the renal artery, after TEVAR for chronic type B dissection for treatment of DIC.…”