Emergent Total Endovascular Repair Using Retrograde in Situ Branched Stent Grafting for Ruptured Retrograde Aortic Dissection

Figures

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  Fig. 1. Preoperative computed tomography angiography. (A) Three-dimensional reconstruction image showing a patent false lumen from the aortic arch to the descending aorta, with a maximum arch aneurysm diameter of 33 mm. Arrows indicate the primary entry tears in the distal arch and descending aorta. (B, C) Axial views showing the primary entry tears in the distal arch (B) and descending aorta (C). (D, E) Axial views demonstrating high-attenuation hematoma in the pericardial space (D) and mediastinum (E). (F) Sagittal view showing the dissection extending from the ascending aorta proximally to the superior mesenteric artery level distally. Overall, the findings indicate a partially thrombosed retrograde aortic dissection (SVS/STS classification: Type B0,7). SVS/STS, Society for Vascular Surgery/Society of Thoracic Surgeons

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  Fig. 2. Intraoperative angiography and postoperative three-dimensional computed tomography. (A) Initial intraoperative angiogram. (B) The Hanako PTGBD needle (30 cm; Koken Co., Ltd.) used for the puncture. The tip is manually bent to an optimal angle tailored to the anatomical angle between the target carotid artery and the aorta. (C) Dilation of the fenestration using an Athletis PTA balloon dilatation catheter (7 × 40 mm; Boston Scientific). The presence of a “waist” during the early phase of balloon inflation confirms that the wire accurately penetrates the stent-graft fabric. (D) Deployment and dilation of the GORE VIABAHN VBX Balloon-Expandable Endoprosthesis (8 × L-59 mm; W.L. Gore & Associates). The proximal end of the VBX protrudes sufficiently (approximately 2 cm) into the aortic lumen. (E) Completion angiogram. (F) Three-dimensional computed tomography image one year after RIBS showing no endoleak and favorable aortic remodeling with complete thrombosis of the false lumen. PTGBD, percutaneous transhepatic gallbladder drainage; PTA, percutaneous transluminal angioplasty; RIBS, retrograde in situ branched stent grafting; VBX, VIABAHN VBX

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  Fig. 3. Blood flow interruption techniques for stroke prevention. (A) Manual compression of the right common carotid artery. This maneuver demonstrates temporary blood flow interruption to prevent cerebral embolism during the passage of the stent graft through the aortic arch. (B) Angiogram during blood flow interruption in the present case (single-branch RIBS). Blood flow is interrupted by manual compression of the right common carotid artery, direct clamping of the left common carotid artery, and balloon occlusion of the left subclavian artery. At this time, only cerebral perfusion via the vertebral arteries is maintained, showing retrograde contrast flow in the left vertebral artery (subclavian steal). RIBS, retrograde in situ branched stent grafting