DEMOGRAPHICS
45-year-old previously healthy male presenting with severe chest and back pain.
HISTORY
The patient underwent computed tomographic angiography (CTA) which demonstrated a type A10 aortic dissection. The dissection extended into the innominate, SMA and left common iliac artery. The celiac, left renal and IMA originated from the false lumen. He underwent ascending aortic replacement with valve sparing root replacement and an Ascyrus Medical Dissection Stent (AMDS) was placed antegrade to the descending thoracic aorta without guidewire support. On postoperative day 1 the patient developed right leg ischemia, right flank pain and elevated creatinine to 144 umol/L. CTA demonstrated placement of the AMDS stent in the false lumen with poor enhancement of the right kidney.
PLAN
In a hybrid OR, systolic pressure gradient between the left radial arterial line and right femoral measured 50mmHg. Angiogram demonstrated filling of the celiac, SMA, and left renal artery, with delayed filling of the right renal and right iliac artery. The backend of an 0.018 wire and 7Fr steerable sheath were used to puncture the dissection flap to the true lumen and cannulate the right renal artery. A 6mm balloon expandable stent was placed. The steerable sheath was then used with an angled catheter and glidewire to navigate through an intimal tear to the right common iliac artery. The wire was snared. A 12 x 60mm angioplasty balloon was used to fenestrate the septum. There was no further pressure gradient between the radial and femoral lines, and a palpable femoral pulse. His symptoms resolved and CTA demonstrated perfusion of the right renal artery (Figure 1B) and distal aortic fenestration perfusing the right common iliac artery (Figure 1C).
DISCUSSION
Inadvertent stenting of the false lumen is underreported in the literature. Without prompt recognition, morbidity and mortality are high. Intervention should be guided by clinical symptoms versus radiographic findings alone. Several endovascular salvage strategies exist, including extension of the stent from false to true lumen or fenestration of the dissection membrane, and must be tailored to each patient’s anatomy. This report adds to the limited literature with unique patient anatomy and a successful salvage strategy.
Figure 1:A)AMDS in the false lumen with compressed true lumen B)Right renal artery stentC)Balloon fenestration of the septum to improve flow to right iliac
