Emergency thoracic aortic stent grafting for acute complicated type B aortic dissection after a previous abdominal endovascular aneurysm repair

A rare case of an acute type B aortic dissection contained infrarenal rupture of the false lumen after prior endovascular abdominal aneurysm repair

New-onset acute type B aortic dissection after prior endovascular aneurysm repair is extremely rare. Extension of an aortic dissection can cause destabilization of the previously implanted stent graft, thrombosis of the stent graft, and rupture of the aneurysmal sac, with high mortality without therapy. This report describes the case of a 66-year-old patient complaining of sudden abdominal pain radiating to both flanks. Computed tomography angiography of the aorta revealed acute type B aortic dissection with infrarenal rupture of the false lumen after endovascular abdominal aneurysm repair 5 years prior. The patient underwent infrarenal open surgical conversion with suprarenal aortic clamping and implantation of a bifurcated Dacron graft. Postoperatively, no serious complications resulted from the treatment, except for fascial dehiscence. In such cases, the patients can be treated in an emergency situation with open repair, despite the high risk of complications and mortality.

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.

Surgical and endovascular repair for type B aortic dissections with mesenteric malperfusion syndrome: A systematic review of in-hospital mortality

OBJECTIVES

Mesenteric malperfusion is a feared complication of aortic dissection, with high mortality. The purpose of this study was to systematically review in-hospital mortality (IHM) of endovascular and surgical management of acute and chronic Stanford type B aortic dissections (TBAD) complicated by mesenteric malperfusion (MesMP).

METHODS

A systematic search of English language articles was conducted in relevant databases. Data on patient demographics, procedure details, and survival outcomes were collected. Reports were classified by type of intervention performed. Studies that failed to report patient-level outcomes based on specific intervention performed or IHM were excluded. Retrospective chart review of previously published data from a single institution was also performed to further identify cases of TBAD that were managed endovascularly. The Fisher exact test was performed to determine statistical significance.

RESULTS

In total, 37 articles were suitable for inclusion in this systematic review, which yielded 149 patients with a median age 55.0 years (interquartile range, 46.5-65 years) and 79% being male. Overall, in-hospital mortality was 12.8% (19/149) and was similar between endovascular and open surgical interventions (13% vs 11%, P = .99). Among endovascular strategies, IHM was greater, although not statistically significant in the thoracic endovascular aortic repair group compared with the fenestration/stenting without thoracic endovascular aortic repair group (24% vs 11%, P = .15).

CONCLUSIONS

Multiple strategies exist for the management of TBAD with MesMP; however, a majority of cases were managed endovascularly. Despite advances in therapies, mortality remains high at 13%.

Collapsed endograft and lower limb ischemia from type B dissection repaired with thoracic endovascular aortic graft and iliac stenting: A case report and review of the literature

The collapse of an abdominal aortic endograft is a rare event. We present the case of a 60-year-old man with an abdominal endograft who came to the emergency department with chest, back, abdominal, and lower extremity pain in addition to a cool left foot. On imaging, he was found to have a type B aortic dissection and a collapsed abdominal endograft. Subsequently, the patient was taken to the operating room and treated with a thoracic endovascular aortic repair, abdominal aortic cuff, and an iliac stent. Our study details this case and thoroughly reviews similar cases in the literature.

Stent graft in abdominal aortic aneurysm collapsed suddenly after thoracic endovascular aortic repair

Stent graft collapse due to aortic dissection is an extremely rare event. Although endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) are increasingly being performed, various complications can occur. We report a case of collapse of a stent graft, which was used to repair an abdominal aortic aneurysm (AAA) after TEVAR for thoracic aortic aneurysm (TAA). A 72-year-old man with a 77 mm AAA and 60 mm TAA underwent EVAR and a TEVAR 2 months later, respectively. CT performed after the TEVAR showed thoracic aorta dissection with associated AAA stent graft collapse. The graft collapsed was due to superior mesenteric artery obstruction. An emergency TEVAR was performed, and the procedure improved the collapsed graft; however, the endoleak of the AAA stent graft persisted. The AAA expanded over several days, warranting an open repair. Our case provides an insight into the cautionary indications for endovascular therapy.

Type A Thoracic Aortic Dissection Following Endovascular Repair of a Common Iliac Artery Aneurysm

We discuss a rare case of acute Type A thoracic aortic dissection (TAAD) following endovascular aneurysm repair (EVAR) of a common iliac artery aneurysm, which likely resulted from complications due to aberrant anatomy. Valve replacement, ascending aortic arch graft, and entry tear suture repair were necessary to contain the TAAD. Postoperative computed tomography with angiography (CTA) demonstrated stable disease, and the patient remained asymptomatic. Open and endovascular repair of the descending abdominal aorta was avoided. Few cases in the literature report TAAD following EVAR. Detection and repair of the entry site was crucial for containing the TAAD.

Acute Type A Dissection Causing Impending Rupture of Abdominal Aortic Aneurysm Previously Treated with EVAR

This report describes the rapid expansion of a previously excluded abdominal aortic aneurysm (AAA) following type A aortic dissection repair in a 74-year-old male. Following successful Hemiarch replacement, CT angiography (CTA) showed residual dissection throughout the thoracoabdominal aorta, which had created a proximal endoleak at the prior endovascular stent graft resulting in the rapid growth of the residual AAA sac. Urgent thoracic endovascular aortic repair (TEVAR) did not fully obliterate false lumen flow allowing further unstable expansion of the AAA and abdominal pain. This was ultimately managed with an open replacement of the infrarenal neck with a Dacron interposition graft sewn to the prior EVAR. Postoperative CTA showed resolution of the false lumen communication to the infrarenal AAA and no further endoleak. Open interposition AAA neck replacement is a possible treatment for new-onset endoleak in patients with aortic dissection following prior infrarenal EVAR.

Fatal Complications of New-Onset Complicated Type B Aortic Dissection After Endovascular Abdominal Aortic Aneurysm Repair: Report of 2 Cases and Literature Review

New-onset antegrade Stanford type B aortic dissection (TBAD) after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is rare. The extension of aortic dissection leads to various symptoms and affects the stent graft. Moreover, various symptoms may arise owing to a stent graft being present. We describe 2 cases of complicated acute TBAD occurring after EVAR, which were ultimately fatal. The case in which rupture occurred could not be treated and the patient died. In another case with bilateral lower extremity malperfusion caused by collapse and occlusion of the endograft, extra-anatomical bypass was performed. Although the collapsed endograft gradually re-expanded, the patient ultimately died because of multiorgan failure. We have reviewed the literature and analyzed the treatment of complicated TBAD after EVAR.

Acute Type B Dissection Causing Collapse of EVAR Endograft and Iliac Limb Occlusion

We describe a rare case of acute type B dissection (ATBDs) causing collapse of a previously placed infrarenal stent graft, resulting in acute limb ischemia due to left iliac limb thrombosis in a 59-year-old male. The patient presented with acute back and abdominal discomfort radiating to his back, bilateral buttock stabbing discomfort and left > right thigh and calf rest pain. CT angiography showed a spiral type B dissection with collapse of the proximal portion of the endovascular repair of aortic aneurysm (EVAR) device and left limb occlusion. Urgent treatment with thoracic endovascular aortic repair distal to the left subclavian covered the entry tear and redirected the majority of the flow to the true lumen leading to near immediate expansion of the proximal portion of the EVAR device. After surgical femoral control, balloon embolectomy of the occluded iliac limb was performed and the limb relined. His lower extremity ischemic symptoms resolved, and his abdominal and back pain dissipated. At latest 6-month follow-up, CT angiography shows an intact thoracic endovascular aortic repair stent graft and a widely patent EVAR stent graft, and the patient has no further abdominal, back, or leg symptoms. ATBD causing proximal abdominal EVAR collapse is an extremely rare presentation of false lumen pressurization and can be treated similarly to complicated type B dissection with the goal of restoring true lumen patency.

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.

Thoracic endovascular aortic repair for complicated chronic type B aortic dissection in a patient on hemodialysis with recurrent ischemic colitis

We present a successful case of thoracic endovascular aortic repair (TEVAR) for chronic Stanford type B aortic dissection (B-AD) with recurrent ischemic colitis. The patient was a 56-year-old woman with abdominal pain as the main complaint who had two operations previously: the total arch replacement 8 years ago and the Bentall 7 years ago for acute Stanford type A aortic dissection. Her abdominal pain worsened as her blood pressure became low during her hemodialysis treatment. An enhanced computed tomography scan was performed on the patient and showed chronic B-AD that occurred from the distal anastomotic part of the total arch graft to the bilateral common iliac arteries. The celiac artery and superior mesenteric artery (SMA) arose from the true lumen, and these were compressed by the expanded false lumen. Her complicated chronic B-AD was treated with the Zenith Dissection Endovascular System, and its procedure was performed as her proximal entry tear was covered by a proximal tapered Zenith TX2 stent graft, supplemented by a noncovered aortic stent extending across both renal arteries, the SMA, and the celiac artery. Seven days after this operation, enhanced computed tomography showed that the patient's true lumen was expanded and her blood flow to the true lumen and SMA was improved. On the other hand, her false lumen tended to be thrombosed. Consequently, she was discharged 10 days after the operation without any postoperative complications as she had no abdominal complaints even though she underwent hemodialysis three times per week after the operation. We believe that TEVAR supplemented by a noncovered aortic stent is an effective treatment, even for highly chronic B-AD in dialysis patients.