Ali Azizzadeh, Kristofer M. Charlton-Ouw, Anthony L. Estrera, Hazim J. Safi
University of Texas Houston Medical School, Houston, TX.
OBJECTIVE: Acute Type B aortic dissection (TBAD) complicated by malperfusion is a challenging clinical entity. Thoracic endovascular repair (TEVAR) may be an alternative to open surgery in these patients. We present a patient with complicated TBAD and aortic arch involvement who was not a TEVAR candidate. Open fenestration was performed with resolution of the ischemic symptoms.
METHODS: A 53-yo woman with hypertension presented with chest pain. Workup revealed evidence of TBAD with involvement of the aortic arch (innominate, left carotid, and left subclavian arteries). There was radiographic evidence of visceral and renal malperfusion. Medical anti-impulse therapy was initiated. The patient subsequently developed abdominal pain. Laboratory values showed elevated liver function tests, coagulopathy, and acute renal failure consistent with visceral and renal ischemia. An aortogram confirmed absence of flow to the celiac, superior mesenteric and left renal arteries. Intravascular ultrasound showed TBAD with complete true lumen collapse.
RESULTS: Open fenestration was performed through a left thoracoabdominal approach. The aorta was clamped above the diaphragm and at the aortic bifurcation. Through a longitudinal aortotomy, the complex dissection flap (septum) was resected. The aorta was then closed primarily. The patient had an uneventful postoperative course. Her laboratory values returned to normal. She was discharged home on POD #12 in stable condition.
CONCLUSIONS: Open fenestration is a suitable option in selected patients with acute TBAD complicated by malperfusion. TEVAR was not an option in this patient due to aortic arch involvement. Vascular surgeons who treat patient with TBAD should be familiar with open fenestration techniques.
TECHNICAL DESCRIPTION: This video describes the open fenestration technique in a patient with acute Type B aortic dissection complicated by malperfusion.
AUTHOR DISCLOSURES: A. Azizzadeh, Gore, Consulting fees or other remuneration, (payment)Medtronic, Consulting fees or other remuneration (payment); K. M. Charlton-Ouw, Nothing to disclose; A. L. Estrera, Nothing to disclose; H. J. Safi, Nothing to disclose.
Posted April 2012