On September 12, 2024, during the 9th China Vascular Conference (CVC 2024), the annual Top 10 Case Showcase of the Vascular Surgery Group of the Chinese Clinical Case Database was successfully held. Numerous surgical experts provided in-depth analysis and experience sharing on the selected top 10 cases of the year. During the event, Professor Chen Jinjie from Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, shared a case of Stanford Type A aortic dissection combined with acute myocardial infarction, treated through surgery and IABP-assisted therapy. 

Case Sharing

Patient Information (Male, 41 years old)

Medical History: One hour before admission, the patient experienced sudden severe bilateral chest pain that could not be relieved, without accompanying symptoms such as nausea, vomiting, or palpitations. He was brought to the emergency department by 120 ambulance.

Past History: History of hypertension and hyperlipidemia, with a maximum blood pressure of 180/110 mmHg. In 2017, the patient underwent coronary artery stent placement in the left anterior descending artery due to coronary artery disease and had been taking aspirin (100 mg) long-term.

ECG: Consideration of anterior wall ST-segment elevation myocardial infarction.

Emergency Coronary Angiography: Occlusion of the left anterior descending and right coronary arteries.

Surgical Procedure

Procedure 1: On April 15, 2024, the patient was admitted to the emergency department due to chest pain. Emergency coronary angiography showed occlusion of the left anterior descending and right coronary arteries. Despite attempts, the vessels could not be opened, so tirofiban was administered intravenously for antiplatelet therapy.

Procedure 2: The patient’s chest pain persisted, and a full aortic CTA revealed Stanford Type A aortic dissection, as well as occlusion of the right common iliac and femoral arteries. Cardiac ultrasound indicated the formation of a left ventricular apical aneurysm, with reduced left ventricular systolic function (EF 42%).

Procedure 3: The patient underwent ascending aorta replacement, total arch replacement, stent graft placement in the descending thoracic aorta, and coronary artery bypass grafting under general anesthesia and cardiopulmonary bypass.

Procedure 4: After cessation of cardiopulmonary bypass, the patient developed repeated ventricular fibrillation. An intra-aortic balloon pump (IABP) was implanted in the hybrid operating room, and a stent was placed in the right femoral artery to restore blood flow. After stabilizing the patient’s vital signs, he was transferred to the ICU for continued treatment.

Procedure 5: Postoperatively, the patient exhibited abnormal consciousness and difficulty waking up. A tracheostomy was performed on the seventh postoperative day, and the IABP was removed on the ninth postoperative day. The patient gradually weaned off the ventilator and was transferred to a rehabilitation hospital for further recovery.

Postoperative Follow-Up

During follow-up at the outpatient clinic, the patient’s overall condition was stable. Cardiac ultrasound and full aortic CTA showed satisfactory recovery.

Case Insights

For patients with aortic dissection combined with coronary artery disease, perioperative mortality is high. Therefore, clinicians should aim to detect coronary artery abnormalities in aortic dissection patients as early as possible preoperatively to allow for early bypass surgery and adequate myocardial protection during surgery. Additionally, after opening the aorta, perfusion can be provided through side holes in the perfusion cannula, reducing damage caused by myocardial ischemia during the anastomosis of the brachiocephalic artery, left common carotid artery, and left subclavian artery. IABP can still be used as an auxiliary measure for low cardiac output after surgery in aortic dissection patients, but care must be taken to ensure proper placement of the balloon in the true lumen.