Fenestration of an Iatrogenic Aortic Dissection After Endovascular Aneurysm Repair

Type B Acute Aortic Dissection as a Perioperative Complication after an Endovascular Abdominal Aortic Repair

Type B aortic dissection (TBAD) is a rare but catastrophic complication of endovascular aneurysm repair (EVAR). We report two cases of TBAD occurring in the perioperative period of EVAR. The intraoperative and postoperative courses were unremarkable. Routine postoperative computed tomography angiography (CTA) revealed TBAD. Conservative treatment was successful, and no adverse aortic events occurred. TBAD that occurs in the perioperative period is likely to be iatrogenic in origin, uncomplicated, and managed with medical therapy: its prognosis is better than when the condition develops in the midterm postoperative period.

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.

Radiological Evaluation of Abdominal Endovascular Aortic Aneurysm Repair

Endovascular aortic aneurysm repair (EVAR) is an alternative to open surgical repair of aortic aneurysms offering lower perioperative mortality and morbidity. As experience increases, clinicians are undertaking complex repairs with hostile aortic anatomy using branched or fenestrated devices or extra components such as chimneys to ensure perfusion to visceral branch vessels whilst excluding the aneurysm. Defining the success of EVAR depends on both clinical and radiographic criteria, but ultimately depends on complete exclusion of the aneurysm from the circulation. Aortic stent grafts are monitored using a combination of imaging modalities including computed tomography angiography (CTA), ultrasonography, magnetic resonance imaging, plain films, and nuclear medicine studies. This article describes when and how to evaluate aortic stent grafts using each of these modalities along with the characteristic features of several of the main stent grafts currently used in clinical practice. The commonly encountered complications from EVAR are also discussed and how they can be detected using each imaging modality. As the radiation burden from serial follow up CTA imaging is now becoming a concern, different follow-up imaging strategies are proposed depending on the complexity of the repair and based on the relative merits and disadvantages of each imaging modality.

Type B aortic dissection after standard endovascular repair of abdominal aortic aneurysm

Dissection of the aorta is a rare yet potentially serious complication following endovascular abdominal aortic aneurysm (EVAR). These can lead to visceral branch hypoperfusion, compromise of aneurysm exclusion, arterial dilation or rupture. Intimal injury and dissection in the context of EVAR may be associated with a number of risk factors that include adverse infrarenal neck morphology, device oversizing, barbed fixation and wire manipulation in the proximal aorta. Herein, we describe three cases of type B aortic dissection following EVAR and discuss possible causes. As the applicability of endovascular technology widens, clinicians are reminded of the importance of early recognition and detection of unusual sequelae following EVAR.