Subtotal Pericardiectomy Research Articles

Subtotal Pericardiectomy and Epicardiectomy for Treatment of Septic Pericarditis and Constrictive Epicarditis in a Dog

ABSTRACT A 1 yr old, 1.7 kg, spayed female Chihuahua was presented for respiratory distress and an enlarged cardiac silhouette as seen on thoracic radiographs. Echocardiogram revealed pericardial effusion and cardiac tamponade. Computed tomography revealed marked pleural and pericardial effusion, thickening of the pericardium caudally, and a mass along the mediastinum. Pericardial fluid obtained via pericardiocentesis showed suppurative inflammation with mixed anaerobic bacteria isolated on culture. Subtotal pericardiectomy and partial lung lobectomy was performed to treat septic pericarditis. Postoperative echocardiogram showed increased right-sided pressures consistent with constrictive epicarditis, and 10 days after surgery, the dog was re-presented for right-sided heart failure. An epicardectomy was performed. A definitive source of infection was not identified, although a penetrating foreign body (e.g., grass awn) was suspected. The dog recovered and 10 yr follow up revealed no evidence of constrictive pathology on echocardiogram. This case report demonstrates the successful treatment of septic pericarditis and constrictive epicarditis via subtotal pericardiectomy and epicardiectomy.

Anaesthetic management in a dog with constrictive pericarditis complicated with bi‐atrial enlargement and atrial fibrillation undergoing subtotal pericardiectomy

AbstractA 2‐year 8‐month‐old female dobermann presented for a recheck after previous crown reduction and vital pulp therapy. On cardiac auscultation, rapid and irregularly irregular heart rhythm and irregular and asynchronous pulses were detected. On electrocardiogram and transthoracic echocardiogram, findings were suggestive of constrictive pericarditis complicated with bi‐atrial enlargement and atrial fibrillation. Subtotal pericardiectomy was performed. The patient was premedicated with methadone (0.2 mg/kg intravenously), and anaesthesia was induced with midazolam (0.2 mg/kg intravenously) and propofol (60 mg), and maintained with isoflurane in oxygen. Constant‐rate infusions of fentanyl (0.1–0.2 µg/kg/min) and lidocaine (50 µg/kg/min) were administered. Dobutamine (1–5 µg/kg/min) helped to maintain mean arterial blood pressure above 65 mmHg. Fluid resuscitation and noradrenaline infusion (0.1 µg/kg/min) started after constriction was released to optimise preload. Haemodynamic support and ventricular rate control continued during the immediate postoperative period. Recovery from general anaesthesia was uneventful.

Description of the management of a pyopericardium due to Neisseria animaloris in a cat

AbstractA 4‐year‐old, European, male neutered cat was admitted to the emergency service showing symptoms of dyspnoea and lethargy. Radiographs and echocardiography confirmed a pericardial effusion. Fluid analysis obtained via thoracocentesis showed evidence of bacteria in the pericardial space. The species of bacteria was Neisseria animaloris. Subtotal pericardiectomy through sternotomy was the treatment of choice in this case to perform a surgical lavage and the placement of a thoracic drain in order to decrease the pericardial pressure. Sterile samples were taken during the surgery. The cat was discharged 6 days after admission, with oral antibiotic treatment (amoxicillin/clavulanic acid) and was free of clinical signs at discharge.

A Surgical Approach: A Heart in a Rigid Cage

Constrictive pericarditis is an uncommon disease with multiple aetiologies. The most common cause usually is idiopathic. In developed countries, constrictive pericarditis is usually a consequence of previous cardiac surgeries and tuberculosis remains as the common causes especially in developing countries. Medical treatment may temporarily relieves the symptoms but most patients undergoes pericardiectomy has better prognosis than medical treatment alone; in comparison on the outcome of total pericardiectomy and subtotal pericardiectomy done in these patients.

Salvation to Hearts in Distress under Shells of Stress: Subtotal Pericardiectomy in a Series of 9 Patients with Constrictive Pericarditis

Objective: Chronic constrictive pericarditis (CCP) is a rare entity responsible of diastolic heart failure. The true prevalence is yet to be defined. The purpose of this study was to describe the clinical and para-clinical characteristics of patients with CCP, the therapeutic management, the outcomes and impacting factors. Materials and Methods: We conducted a retrospective descriptive study from 2017 to 2020 including 9 patients hospitalized for CCP in our cardiovascular surgery department. Results: The mean age was of 32.6 years. Majority were men (n=7). Dyspnea was the most common sign. Peripheral signs were dominated by signs of right heart failure. Cardiac ultrasonography showed pericardial thickening and calcifications with Doppler adiastolic signs in 90% of cases. Thoracic CT was performed in 7 patients, cardiac MRI in one patient, showing calcifications and measuring the pericardial thickening. Cardiac catheterization performed in 6 patients showed the aspect of Dip plateau. Tuberculosis etiology was retained in 55.6%; post-radiation origin in one patient and 33.4 % of cases were idiopathic. All of patients benefited from subtotal pericardiectomy with good results in the medium and long term. Two deaths occurred, the first patient died following multi-visceral failure, the second died 3 years later from neoplasia. Conclusion: The CCP is a rare condition with poor prognosis. The diagnosis should be raised when there are signs of right heart failure associated with signs of hemodynamic adiastolia. The echocardiography, with computed tomography or cardiac MRI and especially cardiac catheterization confirm the diagnosis and also etiological orientation. Tuberculosis and idiopathic etiologies were the most common at our country. Medical treatment options are limited. Pericardiectomy remains the only radical treatment with good results in immediate, medium and long term.

Concurrent intrapericardial–pulmonary hydatidosis: an unusual multisystem echinococcosis

A 46-year-old male presented with breathlessness for a few months. He had been operated twice for liver hydatid cysts and once for right pulmonary hydatid cysts at other hospitals. Now he was found to have one hydatid cyst in the upper lobe of the left lung and multiple hydatid cysts adjoining left heart border. On computed tomography (CT) scan chest and echocardiography, it was difficult to ascertain whether these cysts were pulmonary or intrapericardial. Left ventricular ejection fraction (LVEF) was 25%. Enzyme-linked immunosorbent assay (ELISA) was positive for hydatid. Left posterolateral thoracotomy revealed dead hydatid cyst in upper lobe of the lung that was removed. Infected mother hydatid cyst was encountered inside pericardial sac. Scores of daughter hydatid cysts, varying in size from 1 to 30mm, were scooped out intact from the pericardial cavity. There was significant improvement in cardiac activity, once the tamponade effect of hydatid cyst was removed. Pericardium was about 1cm thick with lot of purulent and necrotic slough. To prevent future constrictive pericarditis, subtotal pericardiectomy was done. Intrapericardial hydatid cyst should be kept in mind whenever it obscures the heart border and patient has features of cardiac tamponade. Early surgical intervention may be required in these cases.

Parasternal Thoracotomy: Review of Twenty-Eight Cases

Pericardiectomy is the preferred surgical procedure for the treatment of pericardial effusions with cardiac tamponade. Surgery is indicated in all cases of recurrent effusions after pericardiocentesis. In the literature, the most frequently used surgical procedure is subtotal pericardiectomy. More recently, minimally invasive techniques have allowed a reduction of morbidity compared to traditional procedures. Aim of this paper is to selectively use the new minimally invasive pericardiectomy technique already described in our previous article and to document the results in a series of twenty-eight cases. Twenty-eight dogs underwent complete blood and urine tests, ultrasound examination, pericardiocentesis and CT scan. In all cases the pericardiectomy was performed via a left parasternal thoracotomy through the seventh intercostal space. All the portions of resected pericardium were measured and histologically examined. All dogs had a neoplastic mass at the base of the heart and no recurrence of the pericardial effusion. All dogs were discharged 24 hours after surgery. Parasternal pericardiectomy may be a good option for the minimally invasive treatment of recurrent pericardial effusions, particularly in the presence of neoplastic lesions of the heart base. The morbidity of the approach is similar to that of other known procedures but it is potentially faster and easier to perform. No dedicated instrumentation is required.

Treatment of idiopathic chylothorax in dogs and cats: A systematic review.

To evaluate the evidence published on the treatment of idiopathic chylothorax (IC) in small animals. Systematic literature review. Dogs and cats with IC. A literature search was performed in three bibliographic databases in July 2018 for publications on IC in dogs and cats. Articles meeting criteria for inclusion were evaluated for treatment, survival, outcome data, and level of evidence (LoE) with a modified Oxford Level of Evidence (mOLE) and GRADE (Grading of Recommendations, Assessment, Development and Evaluations) system. Eleven of 313 identified articles met the inclusion criteria. Only one study was identified in dogs as having higher LoE by using the mOLE system, whereas no study was identified as such in either species with the GRADE system. Surgery was the primary treatment in all dogs and in 93% (68/73) of cats. Medical therapy was the primary treatment in 7% (5/73) of cats. The most common surgical treatment combined thoracic duct ligation (TDL) and subtotal pericardiectomy (SP; 40%; 34/84) in dogs and TDL in cats (51% [37/73]). The body of literature for IC treatment in small animals was limited to one higher LoE study in dogs and none in cats. No strong conclusion could be drawn regarding the effectiveness of any one surgical method in dogs or cats, and no evidence was found to support medical therapy as a primary treatment. The best available evidence regarding the treatment of IC is published in dogs and provides some support for surgical treatment with either TDL + cisterna chyli ablation or TDL + SP. Additional evidence is required to confirm this finding.

Nursing the feline patient following surgical management of idiopathic pericardial effusion by subtotal pericardiectomy

A 4-year-old feline was admitted to the veterinary hospital for haemorrhagic pericardial effusion leading to cardiac tamponade of unknown origin. Concurrent subclinical hypertrophic cardiomyopathy (HCM) was also diagnosed. After significant diagnostic tests and reoccurrence of the effusion, the patient underwent a subtotal pericardiectomy. Results were consistent with neutrophillic/granulomatous pericarditis of unknown origin. This article discusses the nursing care implemented postoperatively, focusing on the major themes of pain management, pain scoring, management of the thoracostomy tube and the correction of dehydration and maintaining the patient's nutritional requirements. After 7 days of hospitalisation, the patient recovered well and was discharged.

Tratamiento quirúrgico de la pericarditis constrictiva; 15 años de experiencia

Introduction and objectivesConstrictive pericarditis is a rare disease with a high morbidity and mortality. His treatment is the surgical pericardiectomy. The aim of this study is to present our experience and analyze the short and long-term outcomes. MethodsAll patients who were underwent to a subtotal pericardiectomy for constrictive pericarditis from january 2003 to february 2018 were included. A description of the serie was made, short and long-term outcomes and mortality risk factors were analyzed. ResultsA total of 53 patients were underwent to a subtotal pericardiectomy. The mean age was 60.5 years (±10.3). The 71.7% were males. The most frequent etiology was idiopathic (52.8%), followed by infectious/inflammatory (28.3%) and postcardiotomy (11.3%). A 62.3% of the patients had NYHA functional class III-IV preoperatively. In-hospital mortality rate was 11.3% (n=6). There were no recurrences in follow-up. Median postoperative follow-up was 64.9 months (IQR 3.1 – 131.2). One, 5 and 10 years survival rates were 86.4%, 81.6% and 75.1%, respectively. NHYA functional class IV was the only independent factor of risk of long-term mortality. ConclusionsPericardiectomy is the surgical technique of choice for the treatment of constrictive pericarditis. Although it is a procedure with high morbidity and mortality, it can be significantly reduced if the indication for surgery is early, before the appearance of refractory symptoms. In addition, an aggressive surgical technique prevents recurrence in long-term follow-up.

Outcomes of dogs with recurrent idiopathic pericardial effusion treated with a 3-port right-sided thoracoscopic subtotal pericardiectomy.

To describe a 3-port right-sided thoracoscopic subtotal pericardiectomy (TSP) to treat dogs with recurrent idiopathic pericardial effusion (RIPE) and report their long-term survival. Retrospective case series. Sixteen client-owned dogs. Medical records were searched for dogs with idiopathic pericardial effusion that recurred after 1 or more pericardiocenteses and treated with a 3-port right-sided technique (1 subxiphoid camera port and 2 instrument ports on the right side of the dog). Follow-up consisted of direct examination or communication with referring veterinarians or owners. Thoracoscopic subtotal pericardiectomy was successfully completed in all dogs, with no surgical complications. The median duration of postoperative follow-up was 191.5 days (range, 5-1345). The median survival time (MST) after surgery was 365 days (range, 5-1345); MST of dogs with a histopathological diagnosis of neoplasia (n = 4) was 76 days, whereas dogs with no evidence of neoplasia had an MST of 367 days (n = 12, P = .14). Recurrent pleural effusion was the ultimate cause of death or reason for euthanasia in 8 of 16 dogs. The technique described here resulted in similar surgical times and outcomes for dogs undergoing TSP for RIPE compared with previous studies. Neoplasia was identified in 4 of 16 dogs. Thoracoscopic subtotal pericardiectomy can be readily performed with only 2 instrument ports, both on the same side of the dog, and without 1-lung ventilation. Recurrent pleural effusion led to the death of half of the dogs in this series.

Pericardial Mesothelioma in a Dog: The Feasibility of Ultrasonography in Monitoring Tumor Progression

A 6-year-old neutered male Yorkshire Terrier presented with recurrent pericardial effusion. Although clinical examinations including computed tomography were inconclusive, an exploratory thoracotomy revealed multiple small nodules and plaques on the inner surface of the pericardial sac (Day 1). A subtotal pericardiectomy was performed to prevent cardiac tamponade due to the increasing pericardial effusion, and the resected section of the pericardium was histopathologically diagnosed with mesothelioma. After surgery, chemotherapy with intrathoracic carboplatin was commenced. During the course of the treatment, a detailed follow-up ultrasonographic scan was performed to detect early lesions disseminated on the pleura, originating from the primary pericardial mesothelioma. On Day 101, the minute pleural nodules, which were disseminated lesions as predicted, were successfully imaged by ultrasonography. As the clinical stage advanced, the nodules were observed to gradually increase in size and number, implying tumor progression. These observations highlight the feasibility of ultrasonography in detecting minute disseminated lesions at an early stage, monitoring tumor progression, and thereby, predicting the prognosis of canine pericardial mesothelioma.

Transdiaphragmatic pericardiectomy in dogs

In patients with recurrent pericardial effusions, pericardiectomy is indicated. The purpose of this study was to describe a transdiaphragmatic approach for subtotal pericardiectomy in dogs and to evaluate its feasibility....

The Panzer Heart: A Surgical Challenge

Introduction constrictive pericarditis is an inflammation of pericardium, they develops progressive fibrotic, calcified the pericardium and compressed the myocardium. The aim of this study is to present a case of massive calcified pericardium and to describe the difficult of surgery. Method A 30–year-old woman was admitted in cardiovascular hospital after 7 years of dyspnea, weakness, fatigue, ascites and palpitation. She had been diagnosed with on tuberculosis 8 years before and had complied with anti-tuberculosis chemotherapy. Treatment consists of 4 drugs therapy (rifampicin, isoniazid, pyrazinamide and ethambutol) for 2 months followed by 2 drugs (rifampicin, isoniazid) for 4 months with adjuvant treatment including vitamin B. Clinical examination showed symptoms of right heart congestion including congestive liver; ascites dilated jugular vein and leg edema. Chest radiography showed massive pericardial calcific deposits encircling the left and the right ventricle. Two dimensional echocardiography revealed severe pericardial calcification with right systolic ventricular dysfunction, dilatation fright atrium and inferior vena cava. Chest thoracic scanner was performed and precise the topography of calcification. Right cardiac catheterism was not performed. Abdominal ultrasound showed ascites and cardiac-like liver. The transaminases were high. Result A subtotal pericardiectomy was performed through a median sternotomy without cardiopulmonary bypass (CPB).The anterior, lateral and inferior pericardium was resected between the right and left phrenic nerve using the ultrasonic scalpel. Massive calcified are as were first irrigated with hot physiologic serum, in order to fracture the plaque and dissect it from myocardium without coronary lesion. Our patient was discharged to the hospital 8 days later, electrocardiogram showed atrial fibrillation. After 3 months she no longer presents dyspnea and ascites. Conclusion Surgical decompression of right cardiac cavities in massive calcified pericarditis induce increasing of right signs and restoration of the right ventricular function.

Constrictive Pericarditis as a Cause of Ascites

A 70 year old Caucasian male with a past medical history of asthma, dyslipidemia, mild renal insufficiency and (a one year diagnosis of) cryptogenic cirrhosis based on ascites and pedal edema presented to us with exertional dyspnea, ascites and a 50 pound weight loss in the past 6 months. He was a past smoker with a 7 pack year and quit 30 years ago while his alcohol intake was an average of less than 6 beers/week. He was on diuretics for his ascites and pedal edema. On exam he had a large volume ascites with no stigmata of cirrhosis or liver decompensation. With near normal liver function tests and mild cirrhosis on MRI; we felt his ascites was out of proportion to his liver disease. Upon further review of his MRI abdomen done 11 months ago we also noticed pericardial thickening. Meanwhile a repeat diagnostic paracentesis was negative for infection and malignancy. Based on exam, laboratory findings and imaging we had a working diagnosis of mild autoimmune hepatitis and constrictive pericarditis to be the etiology of the moderate ascites. An MRI, echocardiography and cardiac catheterization indicated symptomatic pericardial thickening with constrictive pericarditis. He underwent a median sternotomy with subtotal pericardiectomy and a month later he no longer has exertional dyspnea, his ascites has resolved and is presently on a tapered dose of diuretics.Figure 1Figure 2

Mediastinectomy for management of chronic pyogranulomatous pleural disease in dogs

The medical records of 12 dogs with chronic pyogranulomatous pleural disease unresponsive to medical management were reviewed retrospectively. Resection of the mediastinal pleura (mediastinectomy) was performed through a median sternotomy...

Mixed Form of Pericardial Mesothelioma with Osseous Differentiation in a Dog

An 8-year-old female Yorkshire terrier was referred for evaluation and treatment of recurrent pericardial effusion. Echocardiographic examination revealed a markedly and irregularly thickened pericardial sac with frequent hyperechoic areas with acoustic shadows. Pericardiocentesis produced only a small amount of thick serosanguineous fluid. The dog underwent subtotal pericardiectomy, but died during surgery. At necropsy examination, the heart was encased by voluminous, grey-white to red-tan, soft to firm proliferative tissue arising from the pericardial sac. The pericardial cavity was obliterated. Microscopically, the tissue was predominantly sarcomatoid with osseous differentiation and epithelioid elements were admixed with bundles of spindle cells. Immunohistochemically, the constituent cells, especially those that were epithelioid, co-expressed cytokeratin and vimentin. A diagnosis of mixed form pericardial mesothelioma with osseous differentiation was made. This appears to be the first report of such a tumour in a dog.

Embolised mesothelial cells in a tracheobronchial lymph node associated with idiopathic chylopericardium in a dog

A 5·5-year-old male castrated Bernese mountain dog presented with respiratory difficulties and was diagnosed with haemorrhagic pericardial effusion which transformed into chylopericardium. Thoracic duct ligation and subtotal pericardiectomy in combination with biopsy of an enlarged tracheobronchial lymph node were performed. Multiple clusters of mesothelial cell emboli were observed in the subcapsular sinus of the lymph node. No causative agent for the pericardial effusion could be identified, suggesting that this is a case of mesothelial cell embolisation associated with idiopathic -chylopericardium in a dog.

Indications et résultats de la chirurgie de la péricardite chronique constrictive à Dakar

The aim of thisstudy isto evaluate the results after surgical treatment of constrictive pericarditis. Patients and method: From 1996 to 2008, 32 patients were operated in Dakar teaching hospital; the mean age was 23 years. Symptoms secondary to venous congestion were present, there were 80% in dyspnea class II NYHA. History of pulmonary tuberculosis was found in 72%. Cardiac catheterization was performed in 50% patients and a characteristic dip and plateau wasfound. Subtotal pericardiectomy (from phrenic nerve to phrenic nerve) through median sternotomy was realised without cardiopulmonary bypass. Histopathological analysis revealed tuberculosis in 60%. Results: Post operative mortality was 6,25 %. Complications were right atrium lesion (12,5%) and phrenic nerve injury (3%). After 5 years, 75% of the patients were in dyspnea classI of NYHA and 6,25% in classII. Conclusion: Subtotal pericardiectomy through median sternotomy is an effective surgical procedure for the treatment of constrictive pericarditis. In Senegal tuberculosisisthe main etiology. Pericardiectomy associated with medical treatment modified functional prognosis of patients

Endoprosthetic exclusion of type A aortic dissection through carotid artery

Even today, totally endovascular repair of the ascending aorta remains only anecdotally reported,1Roux D. Brouchet L. Rousseau H. Elghobary T. Glock Y. Fournial G. Treatment of a fistula at the distal anastomosis after Bentall operation with endoluminal covered stent.Ann Thorac Surg. 2002; 74: 2189-2190Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar although arch2Siniscalchi G. Tozzi P. Ferrari E. Delay D. Ruchat P. von Segesser L. Endovascular repair of aortic arch aneurysm after achievement of local anesthesia.J Thorac Cardiovasc Surg. 2007; 133: 262-263Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar and descending aorta endoprosthetic replacements are currently performed. Recognized treatment of type A dissection still remains emergency replacement of the ascending aorta, with adequate aortic valve and coronary ostial management.3Pretre R. von Segesser L.K. Aortic dissection.Lancet. 1997; 349: 1461-1464Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar We describe a case in which the surgical strategy had to be somewhat innovative. A 64-year-old white man with a history of subtotal pericardiectomy for constrictive pericarditis had undergone a transseptal mechanical valve replacement 33 years previously to treat a degenerative mitral regurgitation. Because of a severe mediastinal fibrosis, we proceeded through a right anterolateral thoracotomy and right venoarterial femoral cannulation. Because of severe hemodynamic instability during cardiopulmonary bypass, arterial cannulation problems were suspected. Finally, retrograde iatrogenic aortic dissection with involvement of the ascending aorta was confirmed by transesophageal echocardiography. An attempt to replace the ascending aorta was undertaken but discontinued because of the extremely dense, fibrous tissue surrounding all cardiovascular structures. The patient's postoperative course was uneventful, with a computed tomographic (CT) scan confirming an untreated type A dissection without aortic regurgitation and with a reentry tear in the ascending aorta (Figure 1, A). The patient was discharged on postoperative day 11 with adequate dosages of β-blocker and angiotensin-converting enzyme inhibitor. Three months later, control CT scan showed a marked 9-mm increase in the aortic diameter (Figure 1, B and C). The only option was an endoprosthetic repair of the ascending aorta. After consent had been obtained, a customized 44 × 70-mm polytetrafluoroethylene-covered endoprosthesis with distal open web (EndoFit; LeMaitre Vascular, Inc, Burlington, Mass) was inserted through a cutdown to the left common carotid artery, the only nondissected supra-aortic vessel. Good positioning of the endoprosthesis, with confirmation of tear and false-lumen exclusion, was checked by intraoperative transesophageal echocardiography. The postoperative course was clinically uneventful, with the absence of any aortic regurgitation on transthoracic echocardiography. CT scan on postoperative day 2 (Figure 2, A) revealed free coronary ostia and aortic valve commissures, with complete thrombosis of the false lumen an without endoleak. At 1-year follow-up, CT scan showed a complete repair of the aortic wall without compromise on the brachiocephalic trunk at the distal part of the prosthesis (Figure 2, B and C). Treatment of iatrogenic type A dissection is emergency replacement of the ascending aorta.4Ruchat P. Hurni M. Stumpe F. Fischer A.P. von Segesser L.K. Acute ascending aortic dissection complicating open heart surgery: cerebral perfusion defines the outcome.Eur J Cardiothorac Surg. 1998; 14: 449-452Crossref PubMed Scopus (53) Google Scholar We had to consider, however, that the only available solution for our threatened patient was an endovascular procedure with remote insertion through the left common carotid artery.5Heidenreich J.H. Neschis D.G. Costanza M.J. Flinn W.R. Endovascular repair of a penetrating thoracic aortic ulcer by way of the carotid artery.J Vasc Surg. 2003; 38: 1407-1410Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar Common carotid clamping is rarely associated with brain ischemia because of collateralization through the external carotid and contralateral facial arteries. In this procedure, we monitored brain ischemia by near-infrared cerebral oximetry with the patient under general anesthesia. This technique is well correlated with clinical neurologic surveillance during carotid endarterectomy with the patient under local anesthesia. Endoprosthesis insertion into the ascending aorta to exclude pseudoaneurysms has already been described,1Roux D. Brouchet L. Rousseau H. Elghobary T. Glock Y. Fournial G. Treatment of a fistula at the distal anastomosis after Bentall operation with endoluminal covered stent.Ann Thorac Surg. 2002; 74: 2189-2190Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar but to our knowledge this is the first description of a mandatory endovascular treatment of type A aortic dissection.