Aortic dissection occurring 18 months after successful endovascular repair in an anatomically difficult case of abdominal aortic aneurysm

Hybrid repair strategies for acute type B aortic dissection complicating prior standard and complex endovascular aortic repair

Type B aortic dissection (TBAD) in the presence of an existing aortic endograft is a rare, but potentially catastrophic, event. False lumen pressurization and propagation leads to several failure modes. Endograft collapse can lead to spinal cord, visceral, or lower extremity ischemia, and rupture of a previously sealed aneurysm sac is often fatal. A successful treatment strategy must incorporate the patient's symptoms, urgency of intervention, extent of dissection, and the location and status of the existing graft. In this series, we present three cases of TBAD complicating prior endovascular aortic repairs-infrarenal, iliac branched, and thoracoabdominal branched endografts-successfully treated with tailored, hybrid interventions.

Acute Type B Aortic Dissection One Month After Fenestrated EVAR Procedure

Introduction

Acute aortic dissection after endovascular repair of an aortic aneurysm is a rare but serious condition, with potential complications that can result in the death of the patient.

Report

This is the case of a patient diagnosed with a type IV thoraco-abdominal aneurysm with involvement of both iliac arteries who underwent endovascular repair with a four fenestration device and a left iliac branch. One month after the procedure, the patient presented with a type B acute aortic dissection that extended from the left subclavian artery to the proximal stent of the fenestrated graft. This dissection was treated by thoracic endovascular aortic repair, and after a problematic post-operative period, the patient was discharged after 30 days.

Discussion

Occurrence of an acute aortic dissection after endovascular repair of an aortic aneurysm has rarely been reported in the literature. Development of these dissections has been related to factors such as excessive oversizing, use of devices with active fixation systems, or injuries during the procedure, although it is believed that the late onset would indicate that it was a de novo dissection. The presence of an aortic dissection can lead to the collapse and occlusion of the previous endograft and even to aortic rupture, and mortality in reported cases reaches 30%. The authors suggest that endovascular treatment should be considered in these patients.

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Aortic dissection in a patient with previous endovascular aneurysm repair is rare.

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Anatomic, device, and procedure factors could be the cause of this situation.

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Type B dissections could lead to collapse of the graft, sac growth, and rupture.

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Aggressive treatment must be considered to prevent serious complications.

Type B Dissection Resulting in Acute Limb Ischemia in a Patient With a History of EVAR

Type B aortic dissection (TBAD) can be complicated due to visceral and limb malperfusion. We present the case of a patient with a TBAD 5 months after endovascular aneurysm repair (EVAR) for an infrarenal aortic aneurysm, which resulted in a right leg acute limb ischemia due to impingement of the EVAR from to the dissection. In the following discussion, we will review the literature and describe our technique for the treatment of this infrequent problem.