Author + information
- Yosuke Hata1,
- Osamu Iida1,
- Shin Okamoto1,
- Takayuki Ishihara1,
- Kiyonori Nanto1,
- Takuya Tsujimura1,
- Shota Okuno1 and
- Masaaki Uematsu1
Patient initials or identifier number
Relevant clinical history and physical exam
A 75-year-old hypertensive woman had sudden extreme back pain. Computed tomography angiography (CTA) revealed Stanford type An aortic dissection from ascending aorta to common iliac arteries, causing symptomatic limb ischemia. Emergent ascending aorta replacement (J-graft 22-mm) and fenestration for the right femoral artery were performed. Reconstruction of the brachiocephalic artery left common carotid artery and left subclavian artery not concurrently performed.
Relevant test results prior to catheterization
Immediate postoperative CTA showed a distal aortic arch diameter of 41 mm and a patent false lumen, but CTA one month postoperatively revealed distal aortic arch enlargement to 52 mm, considered high-risk for rupture. Surgery advised against re-operation for false lumen closure, because of relatively high risk for perioperative complications with open surgery. Therefore, we planned endovascular closure of the dissection entry point at the proximal descending aorta.
Relevant catheterization findings
The latest CTA revealed two entry points in the distal aortic arch and proximal descending aorta. Reentries were also located in the bilateral iliac arteries. We planned endovascular closure for the proximal descending aorta entry site using an Amplatzer Vascular Plug 2, with coil embolization from the false lumen to a distal arch of true lumen, and stent graft coverage for the left iliac artery using the Excluder iliac extender.
Under general anesthesia, left common femoral artery was exposed via the inguinal incision. A 5Fr, 10 cm sheath inserted from the right brachial artery for control angiogram. A 0.035-inch Radifocus wire inserted to distal false lumen from reentry at the left iliac artery and advanced into a right iliac artery through a false lumen. False lumen at right iliac artery embolized with a 4 mm Amplatzer vascular plug and Tornado coil. Location of target entry site confirmed by simultaneous angiography from descending aorta of false and true lumen under rapid pacing at 200 bpm. A 0.014-inch wire crossed to true lumen from false lumen, and a 6Fr, the 90 cm sheath cannulated into true lumen via entry at proximal descending aorta. Amplatzer vascular plug 2 advanced through the 7Fr,45 cm sheath until the first disk opened in true lumen of the proximal descending aorta. The plug and sheath were withdrawn en bloc until the opened first disc seated on the true lumen side of the entry. The second-third discs were released in the false lumen. We added coil embolization for the false lumen of distal aortic arch using penumbra detachable coil. Finally, Excluder iliac extender inserted and deployed in the true lumen for a left iliac artery.Completion angiography revealed closure of entries and reentries and reduction of false lumen blood flow. Operative time was 60 min, and an amount of contrast media was 200 ml.
We performed endovascular entry closure of aortic dissection with Amplatzer vascular plug 2. At one month postoperatively, CTA revealed false lumen of the aortic arch to descending aorta was thrombosed, and distal aortic arch had shrunk to 38 mm. Chronic dissection with residual entries after ascending aorta replacement for Stanford type A dissection and enlargement of the false lumen can occur. Re-operation for an aortic arch replacement has a relatively high risk for perioperative complications. As an alternative to open surgery, we successfully performed entry closure of residual dissection and reduced risk for rupture of a distal aortic arch with a minimally invasive endovascular procedure.