Intravascular Ultrasound–Guided Percutaneous Fenestration of the Intimal Flap in the Dissected Aorta

BACKGROUND: Aortic dissection with branch obstruction is associated with high morbidity and mortality. Fenestration of the dissection flap to relieve distal vessel ischemia is at present largely performed surgically. The surgical mortality and morbidity are high, because most patients are poor candidates for anesthesia or surgery. METHODS AND RESULTS: Nine percutaneous fenestrations (one with additional stenting of the infrarenal true aortic lumen) were performed under local anesthesia in seven patients with aortic dissection. The presenting symptoms were abdominal angina or claudication. By the transfemoral approach, the intimal flap was initially punctured with a needle-catheter combination through which a guidewire was placed across the dissection flap. The fenestration was carried out with a balloon catheter introduced over the guidewire. The procedure was performed under on-line guidance with intravascular ultrasound imaging. The procedure was performed successfully and without complications in all patients. After intervention, symptoms resolved in all seven patients. CONCLUSIONS: Intravascular ultrasound-guided percutaneous fenestration of the intimal flap in symptomatic aortic dissections with distal vessel involvement is a technically feasible and safe procedure that can effectively relieve the patient's symptoms.