Gluteal Artery Access to Embolize False Lumen of Type B Aortic Dissection in Marfan Patient

This case study presents an innovative endovascular approach using percutaneous gluteal artery access for embolizing the false lumen of a type-B aortic dissection in a Marfan Syndrome (MFS) patient. A 63-year-old female patient, affected by MFS and arterial hypertension, was admitted to the emergency room with thoracic pain and dyspnea. Her extensive surgical history included aortic valve replacement, ascending aorta substitution for acute type non-A non-B dissection, total arch replacement using the frozen elephant trunk technique, and thoracic endovascular aortic repair for aneurysmatic evolution of the dissection. Emergent computed tomography angiography (CTA) revealed a type 2 thoracoabdominal aortic aneurysm extending to both iliac axes, with a maximum diameter of 70 mm and all visceral vessels originating from the true lumen also The CTA also showed significant left pleural effusion, indicating potential rupture. An endovascular treatment was deemed the first choice for this patient, and it was planned a T-branch off-the shelf branched endograft positioning, associated with COOK Unibody placement and all visceral artery stenting with self-expandable stents, completed with an iliac branch device for the left common iliac artery aneurysm. Nevertheless, during the procedure, after the iliac branch device in the left iliac artery, it was not possible to cannulate the hypogastric artery, because of the dissection lamella interposition between the endoprosthesis and the artery ostium. The procedure was completed with a bridging endoprosthesis placement trying to exclude the false lumen retrograde reperfusion. Post- procedure, the patient was admitted to the ICU for monitoring and was successfully extubated after 12 hours, exhibiting no complications or spinal cord ischemia symptoms. On the third day post-operation, a CTA revealed ongoing enlargement of the aneurysmal sac due to false lumen perfusion via the left hypogastric artery, along with worsening pleural effusion. Considering the patient unfit for open surgery, an alternative endovascular approach was undertaken. The false lumen embolization was performed from the left hypogastric artery using spiral coils, through an ultrasound-guided left gluteal artery access. The patient was discharged in good general condition. After 6 months, the follow-up CTA showed the good patency of all endografts, visceral arteries, and stents, with a complete exclusion of aneurysm and false lumen. The key aspects of the patient's presentation, intervention, and outcomes, providing insights into this innovative approach to false lumen management of TBAD in MFS patients. Doppler ultrasound-guided percutaneous gluteal artery access was shown safe and effective as a route to embolize false lumen in TBADFig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)