Dear Dr Harky et. al,
We appreciate your inquiry regarding our case report. Dr Harky et. al
suggested that TEVAR for a Marfan patient could be an unnecessary
approach even during the COVID-19 pandemic.
We believe in this particular case, the endovascular approach was fully
justified as the patient had clear signs of end organ ischemia at
presentation. He presented with extreme right leg ischemia with diffuse
numbness. There was no detectable distal arterial flow of the right
extremity by a Doppler and physical evaluation. Contrast computed
tomography scan showed a completely occluded right common iliac artery
and diminished flow to the right renal and celiac arteries due to the
compression of the true lumen from the false lumen. Preoperative
creatinine was elevated to 1.2 mg/dl. She was also suffering ongoing
right kidney malperfusion.
It was during the time when COVID-19 epidemic started spreading rapidly
in New York City. Our hospital beds were filled with COVID-19 patients
and there was a shortage of medical supplies with no ventilators
immediately available. It was important to reduce exposure of the
individual to the hospital environment and minimize length of stay and
ventilator needs. As such, we chose to proceed with TEVAR to minimize
the risk of lung injury which can occur in open repair. Postoperative
respiratory failure is a major issue in open thoracic aortic repair
[1]. The patient did not have a risk of respiratory comorbidities
but we believed that this pandemic placed all patients at risk for
contracting COVID-19 and subsequent acute respiratory distress [2].
Due to the high risk of spinal cord ischemia in this particular patient,
we performed TEVAR with a distal bare metal component to preserve the
blood flow into spinal cord arteries [3]. The initial clinical
treatment plan was to perform the TEVAR as a bridge to open repair. We
obviously will need to follow-up with her carefully and if any signs of
failure of TEVAR is detected, open repair will ultimately be required.
Dr Harky et. al suggested axillary femoral artery bypass to rescue the
ischemic leg, however, this patient also suffered malperfsuion of the
renal and celiac arteries, so further intervention was required.
Thank you for your insightful suggestions.
References
1) Khan FM, Naik A, Hameed I, et al. Open repair of descending thoracic
and thoracoabdominal aortic aneurysms: a meta-analysis. Ann Thorac
Surg . 2020;S0003-4975(20)30865-1.
2) Bai Y, Yao L, Wei T, et al. Presumed Asymptomatic Carrier
Transmission of COVID-19. JAMA. 2020;323:1406–7.
3) Lombardi JV, Cambria RP, Nienaber CA, et al. Five-year results from
the study of Thoracic Aortic Type B Dissection Using Endoluminal Repair
(STABLE I) study of endovascular treatment of complicated type B aortic
dissection using a composite device design. J Vasc Surg. 2019;
70:1072-81.