Open fenestration for complicated acute aortic B dissection

Abstract

Acute type B aortic dissection (ABAD) is a serious cardiovascular emergency in which morbidity and mortality are often related to the presence of complications at clinical presentation. Visceral, renal, and limb ischemia occur in up to 30% of patients with ABAD and are associated with higher in-hospital mortality. The aim of the open fenestration is to resolve the malperfusion by creating a single aortic lumen at the suprarenal or infrarenal level. This surgical procedure is less invasive than total aortic replacement, thus not requiring extracorporeal support and allowing preservation of the intercostal arteries, which results in decreased risk of paraplegia. Surgical aortic fenestration represents an effective and durable option for treating ischemic complications of ABAD, particularly for patients with no aortic dilatation. In the current endovascular era, this open technique serves as an alternative option in case of contraindications or failure of endovascular management of complicated ABAD.

Keywords: Acute type B aortic dissection; malperfusion; open fenestration.

Figure 1

Complete dissection of the thoraco-abdominal-aorta (type B) below the origin of the subclavian artery to the left common iliac artery. In this case the celiac trunk and the superior mesenteric artery are dissected and the left renal artery is excluded.

Figure 2

Aortic axial view showing dynamic (A) dynamic and (B) static obstruction.

Figure 3

In dynamic obstruction (A,B), the septum may prolapse into the vessel ostium during the cardiac cycle, and the compressed true lumen flow is inadequate to perfuse branch vessel ostia, which remain anatomically intact.

Figure 4

Mechanisms of static obstruction. (A) Compression of the vessel by blind ends of the false lumen; (B) presence of true and false lumen in the vessel causing further compression; (C) thrombosis of the vessel distal to the compromised ostia.

Figure 5

Acute type B aortic dissection (ABAD) involving visceral segment.

Figure 6

Exposure is achieved through a thoraco-abdominal incision in the 8^th or 10^th intercostal spaces.

Figure 7

The visceral segment of the aorta is exposed.

Figure 8

The true and false lumen of the aorta is identified.

Figure 9

The visceral ostia after the removal of the intimal flap.

Figure 10

The suture is reinforced with Teflon strips.

Figure 11

This represents the particular of another fenestration technique: (A) transection of the aorta; (B) septum resection.

Figure 12

This represents two type of repair: (A) aortic walls sutures with two Teflon felt stripes; (B) the infrarenal tract of the aorta is also replaced with a surgical graft.