OBJECTIVE: The combination of an ascending aortic dissection with distal extension leading to malperfusion is associated with significant mortality. Prior methods to managing malperfusion are traditionally focused on open interventions or difficult and ineffective endovascular methods. Endovascular electrosurgical septotomy is a known technique for management of chronic aortic dissections. To date, this technique has not been described in the management of an acute aortic dissection. We sought to determine the achievability and efficacy of this technique in management of acute dissection with malperfusion. METHODS: Bilateral femoral artery access was obtained (Left 16 Fr, Right 8 Fr). We accessed the true lumen and false lumen and used IVUS for confirmation. Using an 8.5 Fr steerable sheath and an Astato, the septum was crossed in the proximal descending aorta from the true to false lumen. We snared the wire to allow for through and through access from our bilateral femoral accesses over our septum. We fashioned our Astato wire; it was bent in two spots at the mid portion to allow for a 5 mm straight segment between the two bends. This portion of the wire was shaved to remove the coating. Two Navicross catheters were placed on both sides to provide for additional insulation. With equal tension on both wires and catheters and cautery set on cut mode at 80, caudad tension was pulled on the system and the septum was therefore cut. This was performed from the proximal descending aorta to the bifurcation. RESULTS: Completion angiogram demonstrated excellent results with perfusion of the visceral arteries including the SMA. Completion IVUS demonstrated a dynamic flap of the cut septum with partial covering of the SMA. Although not flow limiting, given concern this might lead to intermittent flow, we elected to perform stenting of the SMA with a bare metal stent. Completion angiogram demonstrated excellent results and perfusion of all visceral vessels. Total operative time was ninety minutes. The patient had early resumption of enteral access feeds and no signs of mesenteric ischemia.CONCLUSIONS: Endovascular electrosurgical septotomy is a minimally invasive and effective approach for management of malperfusion in aortic dissection. This is the first reported case using this technique in an acute dissection. The technical and clinical success demonstrates the feasibility for future use.
