A Reversed Strategy For Treating Type B Aortic Dissection: Open Aortobiiliac Bypass Prior To TEVAR
Maksim V. Gusev, Md, Sheela T. Patel, MD.
Loma Linda University, Loma Linda, CA, USA.
DEMOGRAPHICS Thoracic endovascular stent grafting has been increasingly utilized for patients with acute type B aortic dissection with unfavorable predictors of aortic growth. We present a case of a patient who presented with worsening abdominal pain and a rapidly enlarging right common iliac aneurysm associated with a type B aortic dissection extending into bilateral iliac arteries. He was repaired with an open aortobiiliac bypass graft followed by thoracic stent grafting of the type B aortic dissection. Computed tomographic imaging indicated positive remodeling of the aortic dissection at 2 years. HISTORYThe patient is a 63 year old male who presented with sudden onset of chest pain and right lower extremity pain and weakness. He had no pedal pulses nor signals. CTA indicated type B aortic dissection extending from the left subclavian artery into bilateral common iliac arteries. The true lumen perfused the celiac, superior mesenteric, and bilateral renal arteries. The dissection flap at the aortic bifurcation caused complete occlusion of the right common iliac artery. He was treated with anti-impulse therapy with return of right foot pulses over the next several hours. He was discharged and then presented 2 months later with worsening right lower quadrant pain. CTA indicated an enlarging right common iliac artery aneurysm (from 30 mm to 40 mm). He had unfavorable morphological predictors of aneurysmal degeneration (aortic size > 40 mm, false lumen > 22 mm, entry > 10 mm).PLANHe was repaired with an infrarenal aortobiiliac bypass graft. 5 months later, the patient underwent left common carotid to left subclavian artery bypass graft followed by thoracic stent graft coverage of the proximal intimal tear and distal bare stent extending into the body of the bifurcated aortic dacron graft (provisional graft extension to induce complete attachment, PETTICOAT). CTA at 2 years indicated positive remodeling of the type B aortic dissection.DISCUSSION
This case demonstrates that open infrarenal aortobiiliac graft prior to TEVAR for type B aortic dissection may be a potentially useful strategy to enhance aortic remodeling.
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