Aortic fenestration for acute or chronic aortic dissection: An uncommon but effective procedure

Background: Aortic fenestration is rarely required for patients with acute or chronic aortic dissection. To better define its role and the indications for its use and to evaluate its success at relieving organ or limb malperf usion, we reviewed our experience with direct fenestration of the aorta. Methods: A retrospective analysis of all consecutive aortic fenestrations p erformed between January 1, 1979, and December 31, 1999, was performed. Fou rteen patients, 12 men and two women (mean age, 59.6 years; range, 43-81), underwent fenestration of the aorta. All patients were hypertensive and had a history of tobacco use. By Stanford classification, there were three typ e A and II type B patients. In the acute dissection group (n = 7), indicati ons for surgery were malperfusion in six patients (leg ischemia, 4; renal i schemia, 5; bowel ischemia, 3) and intra-abdominal bleeding from rupture in two. In the chronic dissection group (n = 7), indications for surgery were abdominal aortic aneurysm in 4 patients (infrarenal, 3; pararenal, 1), tho racoabdominal aneurysm in 1, hypertension from coarctation of the thoracic aorta in 1, and aortic occlusion with disabling claudication in 1. Results: Emergency aortic fenestration was performed in seven patients (sur gically for 6 and percutaneously for 1). Fenestration level was infrarenal in four and pararenal in three. Concomitant abdominal aortic graft replacem ent was performed in four patients, combined with ascending aortic replacem ent (n = 1) and bilateral aortorenal bypasses (n = 1). In two patients, acu te fenestration was performed for organ malperfusion after prior proximal a ortic replacement (ascending aorta, 1; descending thoracic aorta, 1). Seven elective aortic fenestrations were performed for chronic dissection (desce nding thoracic aorta, 2; paravisceral aorta, 2; infrarenal aorta, 2 and par arenal aorta, 1). Concomitant aortic replacement was performed in six patie nts (abdominal aorta, 5; thoracoabdominal aorta, 1). Fenestration was succe ssful at restoring now in all 10 patients with malperfusion. Operative mort ality for emergency fenestration was 43% (3/7). The three deaths that occur red were of patients with anuria or bowel ischemia, or both. There were no postoperative deaths for elective fenestration. At a mean follow-up of 5.1 years, there were no recurrences of malperfusion and no false aneurysm form ations at the fenestration site. Conclusion: Fenestration of the aorta can effectively relieve organ or limb ischemia. Bowel ischemia and anuria are indicators of dismal prognosis and emergency fenestration in these patients carries a high mortality Elective fenestration combined with aortic replacement can be performed safely in c hronic dissection. Aortic fenestration is indicated for carefully selected patients with malperfusion and offers durable benefits.