Surgeon-modified fenestrated stent graft deployment in type B aortic dissection

Abstract

The treatment of aortic dissections and aneurysms may be challenging for vascular surgeons. Currently, thoracic endovascular aortic repair is usually the first treatment option for descending aortic pathologies. Left subclavian artery coverage during this procedure is often required to achieve a sufficient proximal landing zone. Most surgeons agree that the left subclavian artery can be selectively covered, but revascularization is preferred to reduce the risk of neurological or ischemic complications. The chimney method, hybrid operations with extra-anatomic bypass, back table or in situ fenestrations are assistive techniques in this procedure. Herein, we present a surgeon-modified fenestrated stent graft for a type B aortic dissection patient.

Keywords: Aortic dissection; endovascular technique; fenestrated; subclavian artery; thoracic endovascular aortic repair.

Figure 1. Preoperative planning on multiplanar reformation images. Diameter of aortic arch selected as the proximal landing zone (Zone 2) was 30 mm. Proximal landing zone length was 25 mm at greater curvature and 11 mm at lesser curvature. The diameter of LSA was 11 mm. The dissection was extended to the LS artery where the false lumen was partially thrombosed. (LCC: left common carotid artery, LSA: left subclavian artery).

Figure 2. A 5 to 6 -cm unsheathed stent graft with surgeonmodified fenestration.

Figure 3. Correct positioning before deployment with radiopaque markers. Marker "8" should be oriented as a line to maintain the fenestration at the superior part of aortic arch.

Figure 4. The strut at the fenestrated area protruding to the left subclavian artery on completion angiography.

Figure 5. Computed tomography with three-dimensional reconstruction at first month. Bare strut at the orifice left subclavian artery can be seen at the left upper image. Initiation of thrombosis of the false lumen is obvious at axial images.