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No Landing Zone, No Time: Hybrid Repair Of Acute Type B Aortic Dissection With Complex Arch And Visceral Involvement
Osama Anis, MD, Jaclyn Milici, Devon Fromer.
Jefferson Abington, Philadelphia, PA, USA.
DEMOGRAPHICS: A 47-year-old man with a past medical history of diverticulitis presented with acute back and dental pain.
HISTORY: On arrival, he was found to be in hypertensive crisis with a systolic blood pressure greater than 220 mmHg. CT angiography revealed a Stanford type B aortic dissection extending from zone 3 to the right common iliac artery (zone 10). Imaging demonstrated a large mobile entry tear in zone 3, a 24 mm proximal false lumen with severe true lumen compression, and multiple fenestrations spanning zones 4-10. The celiac and superior mesenteric arteries were perfused by both lumens, with dissection propagation into the proximal superior mesenteric artery. Renal perfusion was asymmetric, with the left kidney supplied by the true lumen and the right by the false lumen. A triple-barrel morphology was observed at zone 9 and at the renal level. Despite these high-risk features, there were no clinical or radiographic signs of malperfusion. No suitable proximal landing zone for conventional endovascular repair was identified.
PLAN: The patient was admitted to the intensive care unit for medical management of blood pressure. Despite maximal therapy, systolic pressures remained in the 150s. Given the persistent hypertension and complex anatomy, a hybrid surgical approach was pursued. Through a partial sternotomy, the ascending aorta was anastomosed to a three-limbed Dacron graft: a 10 mm limb to the innominate artery and two 8 mm limbs to the left common carotid and left subclavian arteries. This was followed by zone 0 thoracic endovascular aortic repair (TEVAR) with a Cook Zenith Alpha stent graft, along with sequential dissection stents extending to the aortoiliac bifurcation. Intravascular ultrasound and transesophageal echocardiography confirmed accurate true lumen wire placement.
DISCUSSION: This case underscores the complexity of managing hyperacute type B aortic dissection in patients with challenging arch and visceral anatomy. Standard endovascular strategies were not feasible due to inadequate landing zones and severe true lumen collapse. Hybrid arch debranching combined with TEVAR offered a safe and effective alternative, enabling durable repair while preserving visceral perfusion. Early diagnosis, careful surgical planning, intraoperative imaging, and multidisciplinary collaboration remain essential to optimizing outcomes in these high-risk patients.
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