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

Figures

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  Fig 1. Serial computed tomography (CT) evaluations of the infrarenal aorta demonstrating no evidence of rupture at the initial presentation (A), new demonstration of a retroperitoneal hematoma and aneurysm sac expansion after 3 hours (B), and marked expansion and contrast opacification of the aneurysm sac and retroperitoneal hematoma 16 hours after presentation (C).

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  Fig 2. Preoperative computed tomography (CT) angiogram demonstrating type B2,9 aortic dissection (TBAD2,9; A) with contained rupture of a previously excluded infrarenal abdominal aortic aneurysm (B) due to false lumen perfusion.

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  Fig 3. A, Illustration of type B aortic dissection (TBAD) and distal arch aneurysm with false lumen propagation and abdominal aortic aneurysm expansion. Zone 2 thoracic endograft placement (B) did not stop false lumen flow into the previously excluded infrarenal abdominal aortic aneurysm (C). Exploratory laparotomy was next performed with exposure and control of the proximal infrarenal neck. Dacron patches were passed around the infrarenal neck (D), which were cinched and sutured to incorporate the endograft and aortic wall (E). F, Aortic bites were taken away from the left posterolateral aortic wall, which was weakened by false lumen propagation. G, Following completion of the aortic banding, the false lumen was no longer pulsatile. H, Proximal and distal attachment sites were ballooned, and the patient's abdomen was closed primarily. I, Postoperative imaging demonstrated an excellent result with thoracic false lumen thrombosis and no further evidence of aneurysm perfusion.

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  Fig 4. Preoperative computed tomography (CT) angiogram demonstrating type B3,9 aortic dissection (TBAD3,9; A) complicated by proximal endograft (arrow) compression and thrombosis (B).

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  Fig 5. Deployment of a thoracic endograft in zone 3 with a wire placed in the left common carotid artery through the existing carotid-to-subclavian bypass graft (arrows) to guide accurate deployment. The wire also allows for a bailout chimney stent should the endograft encroach on the carotid artery lumen.

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  Fig 6. Preoperative computed tomography (CT) angiogram demonstrating proximal branched endograft compression and subsequent type Ia endoleak in sagittal (A) and axial (B-D) views.