Miscellaneous
Endovascular

Navigating narrow paravisceral true lumen in post-dissection thoraco-AAA EVAR

Endovascular repair of post-dissection thoraco-abdominal aortic aneurysms is often challenged by significant compression of the true lumen at the paravisceral segment, causing main graft difficult deployment, cumbersome target vessel cannulation, and limited long-term bridging stent stability. 

Different types of aortic stent grafts and bridging stents can be selected to overcome these issues; nevertheless, techniques to favour adequate true lumen expansion during repair may improve short- and long-term outcomes. 

University of Padua, Italy
University of Padua, Italy
University of Padua, Italy
Part I - Case presentation

A 56-year-old male patient was referred to our center for asymptomatic, extent V-type post-dissection thoraco-abdominal aortic aneurysm. His medical history included hypertension, severe obesity (140 kg), paroxysmal atrial fibrillation, CAD (EF 36 %) and COPD. 

Previous medical history

In 2018, the patient was referred to another institution for a complicated acute type B aortic dissection with right renal artery and left lower limb malperfusion. He was emergently treated with TEVAR (Gore C-TAG 36-100 deployed in zone 3) to exclude the sole proximal entry tear, with no additional procedures on the right renal artery or left lower limb. 

On the first post-operative day, the patient underwent reintervention for persistent left lower limb ischemia, with a femoro-femoral right-left bypass performed. The post-operative CT angiogram at discharge showed regular exclusion of the proximal entry tear in Zone 3, with residual thoraco-abdominal dissection extended to the aortic bifurcation, with regular patency of celiac trunk (CT), superior mesenteric artery (SMA) and left renal artery (LRA), but complete occlusion of the right renal artery (RRA), with preserved overall renal function and patency of the femoro-femoral bypass.

Current clinical presentation

After a 4-year follow-up, the patient is referred to our institution for post-dissection thoraco-abdominal aneurysmal evolution, with a maximum transverse aortic aneurysm diameter of 6.7 cm at the CT level, associated with true lumen (TL) compression of the paravisceral segment, and a mild infrarenal aortic dilation of 3.3 cm. CT and SMA originated from the TL. RRA was chronically occluded with hypotrophic right kidney, LRA was patent and originated from the false lumen (FL) (Videos 1 and 2, and Figure 1).

Video 1: Preoperative thoraco-abdominal CTA demonstrating the aortic post-dissecting aneurysmal evolution and severe compression of the paravisceral true lumen.
Video 2. 3D CTA of the post-dissecting aneurysmal aorta extending to left common iliac artery. Note severe true lumen compression, no RRA opacification, reduced LRA opacification from false lumen, and femoro-femoral bypass in the lower image portion.
Figure 1. CTA 3D reconstruction (A) with true lumen aortic diameters at the level of visceral vessels according to SVS reporting standards (C-D-E). Proximal and distal entry tears are also shown (B-F).
Figure 1. 3D CTA reconstruction (A) displaying true lumen aortic diameters at visceral vessel level per SVS reporting standards (C-D-E). Proximal and distal entry tears are visible (B-F).

Risk assessment

SVS/AAVS medical comorbidity grading system

  • Cardiac status: recurrent congestive heart failure → 3 
  • Pulmonary status: FEV 1 less than 35 % of predicted value → 3
  • Renal status: normal serum creatinine level (single kidney) → 1
  • Hypertension: requires more than two drugs to control → 3
  • Age:  56 years old → 1

Based on pre-operative assessment, the patient was deemed to be at moderate/severe risk, with an SVS/AAVS score of 2.3.
 
(0 = no risk, 1 = mild risk, 2 = moderate risk, 3 = severe risk)

Available treatment options

We examined several options, including:

Open surgery: 

  • thoraco-phrenic laparotomy with surgical septostomy followed by aorto-visceral reconstruction

Endovascular surgery: 

  • Single-stage total TAAA exclusion
  • Dual/ Multiple-stage TAAA exclusion 
  • TEVAR extension + FEVAR
  • TEVAR extension + BEVAR (outer branches)
  • TEVAR extension + BEVAR (inner branches)
  • TEVAR extension + F/BEVAR
  • TEVAR extension + FEVAR or BEVAR or F/BEVAR + additional endo-procedures for narrow paravisceral true lumen management

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