Simultaneous Surgical Treatment of Type B Dissection Complicated With Visceral Malperfusion and Abdominal Aortic Aneurysm: Role of Aortic Fenestration

Abstract

Aortic dissection occurs in about 5% of patients with coexistent abdominal aortic aneurysm (AAA); combined type B dissection complicated with visceral malperfusion and AAA is an uncommon aortic emergency and patients presenting with complications of thoracic aortic dissection have a dismal prognosis related to difficulties in treatment strategies. Despite tremendous improvement of endovascular techniques, surgical aortic fenestration represents a quick, safe, and effective procedure able to restore flow in an otherwise malperfused aorta. This procedure has to be kept in mind because subsets of patients cannot be treated conventionally due to either prohibitive risk of aortic replacement, anatomic contraindication, or limitations of percutaneous procedures. Herein we report a case of a patient presenting with type B aortic dissection complicated by visceral malperfusion and AAA which was successfully treated simultaneously by open AAA repair and surgical fenestration. We focus on the mechanism of malperfusion and on the role of surgical fenestration.

Keywords: Aortic dissection; Fenestration; Visceral malperfusion.

Figure 1.

(A) Preoperative CT scan demonstrated extension of the dissection from distal arch to proximal neck of abdominal aortic aneurysm; (B) CT image showing true lumen compression of celiac trunk; (C) 3Mensio CT image demonstrating visceral malperfusion due to the false lumen being overpressurized.

Figure 2.

(A) Intraoperative view showing ischemic small bowel; (B) intraoperative view showing forcep opening true lumen of the dissected aorta; (C) incision of the intimal flap; (D) recovery of the small bowel after fenestration and AAA repair.

Figure 3.

(A) postoperative CT scan showing reexpansion of the true lumen; (B) 3Mensio CT scan demonstrating blood flow restored into visceral vessels and the AAA graft replacement.