Staged thoracic endovascular aortic repair for an extensive Stanford type B aortic dissection in a high-risk patient with chronic kidney disease. A case report

Background: Objective: To describe the endovascular management of an extensive Stanford type B aortic dissection (TBAD) in a high-risk patient, treated with thoracic endovascular aortic repair (TEVAR) as the first stage of a staged repair. Introduction: TBAD is a life-threatening acute aortic syndrome. TEVAR is recommended for complicated disease and should be considered in uncomplicated cases with high-risk features. Case presentation: A 66-year-old man with hypertension, type 2 diabetes mellitus, ischemic heart disease and stage 3a chronic kidney disease presented with epigastric pain, nausea and vomiting. Computed tomography angiography showed a TBAD starting distal to the left subclavian artery, with a maximum diameter of 49 mm and a false lumen extending to the iliac arteries. Elective TEVAR was performed five months after symptom onset through a percutaneous femoral access preclosed with Perclose ProStyle. Intravascular ultrasound (IVUS) was used to differentiate the true and false lumens, and two thoracic stent grafts (42 × 42 × 150 mm and 44 × 40 × 150 mm) were deployed from the aortic arch at the origin of the left subclavian artery to proximal to the celiac trunk. He was discharged home improved, with a second stage planned for the residual distal dissection. Discussion: IVUS guidance and percutaneous access allowed a safe proximal repair in a patient with renal impairment; the residual thoracoabdominal false lumen requires staged treatment and close imaging surveillance. Conclusion: Staged TEVAR is a feasible option for extensive TBAD in high-risk patients.