Type Ib endoleak repaired with a thoracic endovascular graft inside previous visceral debranching bypass in a patient with chronic type B aortic dissection Cristina Tello-Díaz, MD, Jose Maria Romero Carro, MD, PhD, Begoña Soto Carricas, MD, PhD, Jorge Moreno, MD, Carmen Aloy Ortiz, MD, and Jaume F. Dilmé, MD, PhD, Barcelona and Madrid, Spain ABSTRACT We present the case of a patient with chronic type B aortic dissection with a previous iliac to visceral debranching graft and thoracoabdominal endograft who, because of a type Ib endoleak and aortic diameter enlargement, required a complex solution involving placement of a thoracic endovascular graft inside a Dacron graft with a 180 curved shape in three-stage surgery. At 9 months of follow-up, he had no evidence of type I endoleaks, and the aortic diameter had decreased. (J Vasc Surg Cases Innov Tech 2023;9:1-5.) Keywords: Dissection; Endograft; Endovascular; Reintervention Type B aortic dissection (TBAD) has an incidence of 2.9 The management of cTBAD is complex, requiring to 4.0 per 100,000 person-years and the incidence has hybrid solutions and, sometimes, multiple reinterven- been increasing.1 Historically, 14 days after the acute tions. We describe the management of a patient with event, TBAD is defined as “chronic.” However, currently, cTBAD, who had previously been treated with a visceral the preferred classification of TBAD is as follows: debranching graft and thoracoabdominal endograft. hyperacute, <24 hours; acute, 1 to 14 days; subacute, 15 The patient presented with progressive enlargement of to 90 days; and chronic, >90 days.2 One of the aims of the aortic diameter due to a type Ib endoleak. Three- treatment of uncomplicated TBADs is to prevent the pro- stage surgery was performed, which included placement gression and aneurysmal degeneration of the aorta. In of a thoracic endovascular graft inside the visceral the chronic phase, TBAD has been estimated to develop debranching Dacron graft with a 180 curved shape. aneurysmal degeneration in >20% to 40% of patients.3 Medical treatment with antihypertensive drugs remains the cornerstone of treatment of chronic TBAD (cTBAD).3 CASE REPORT Surgery is indicated when aortic dilatation >50 to We report the case of a 67-year-old man with a history of 60 mm occurs or symptoms appear. Open surgery has smoking and hypertension who, at 45 years of age, had pre- been the treatment of choice for these patients; howev- sented with an uncomplicated TBAD. The patient provided writ- er, the advent of endovascular treatment has resulted in ten informed consent for the report of his case details and new treatment possibilities. To the best of our knowl- imaging studies. edge, no data are available regarding comparisons be- At the diagnosis, given the absence of complications and cor- tween open and endovascular repair; however, rect perfusion of the visceral arteries and lower extremities, he endografts have shown good results in the subacute was treated conservatively in the coronary care unit with medi- and chronic phases.4 cal treatment of his hypertension and analgesia for pain control. His clinical course during admission was positive, and he was discharged with close follow-up with computed tomography From the Angiology, Vascular Biology and Inflammation Laboratory, and angiography, scheduled every 6 months for the first year. After Department of Vascular and Endovascular Surgery, Sant Pau Institute of 1 year of stability, the imaging test was performed annually. Dur- Biomedical Research, Universitat Autónoma de Barcelona, Barcelona; and the CIBER de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, ing surveillance, a progressive increase in the aortic diameter Madrid. was observed. The aortic diameter had increased from 50 mm Author conflict of interest: none. to 73 mm in 1 year, and it was decided to proceed with surgical Correspondence: Cristina Tello-Díaz, MD, Department of Vascular Surgery, Hos- treatment. pital of the Holy Cross and Saint Paul, Passeig Vall d’Hebron 119-129, Barcelona 08035, Spain (e-mail: ctello@santpau.cat). The patient, who was 57 years old at the time, was in good The editors and reviewers of this article have no relevant financial relationships to physical condition, hypertension as a part of his medical history, disclose per the Journal policy that requires reviewers to decline review of any and a thoracoabdominal aneurysm, Crawford type II. Although manuscript for which they may have a conflict of interest. open surgery was considered, it was finally decided to perform 2468-4287 a hybrid approach to minimize surgical invasiveness. First, a Ó 2023 The Authors. Published by Elsevier Inc. on behalf of Society for Vascular Surgery. This is an open access article under the CC BY license (http:// distal landing zone was created with visceral debranching graft, creativecommons.org/licenses/by/4.0/). and next, endovascular treatment of the thoracic aorta was https://doi.org/10.1016/j.jvscit.2023.101186 performed. 1 2 Tello-Díaz et al Journal of Vascular Surgery Cases, Innovations and Techniques June 2023 Fig 1. A, Three-dimensional computed tomography reconstruction showing hybrid treatment of the type B aortic dissection (TBAD) with complete endograft coverage of the descending thoracic and abdominal aortas and visceral debranching, including salvage of one of the debranching branches with a stent. B, Computed tomography reconstruction showing in detail the visceral debranching bypass from the external iliac artery and the endograft ending in the common iliac artery, at the edge of the visceral bypass. C, Diagram illustrating mobilization of the visceral debranching bypass from the common iliac artery to the external iliac artery to cover the common iliac artery with the endograft. Also shown is stenting of the iliohepatic bypass after thrombectomy. In the first stage, visceral debranching bypass was performed multiple transfusions. His postoperative course was complicated from the left common iliac artery to the right renal artery, supe- by coagulopathy, acute respiratory failure, and infection of the rior mesenteric artery, and hepatic artery (the left renal artery abdominal hematoma requiring a long admission in the inten- was atrophic) with a 16  8-mm Dacron graft (Maquet, Rastatt, sive care unit. His recovery was slow but satisfactory. Germany). In the second stage, the descending thoracic and Despite the previous interventions, in 2014, 1 year after the last visceral abdominal aorta was covered with Valiant 34  34  intervention, type II and III endoleaks were detected. The inferior 100-mm and 34  34  150-mm endografts (Medtronic Vascular, mesenteric artery was embolized with Barricade coils (Blockade Santa Rosa, CA). Medical, Irvine, CA), and three new thoracic stent grafts were One month later, because of a distal endoleak of the previous placed from the distal edge of the left subclavian artery to the endograft and an isolated right common iliac dissection, we previous bifurcated endograft (Valiant 36  36  150 mm, 34  placed a Valiant 34  34  100-mm endograft (Medtronic 34  100 mm, and 34  34  150 mm; Medtronic Vascular). Vascular) in the abdominal aorta and a Talent 18  12  80- After the last surgery, the subsequent computed tomography mm stent graft (Medtronic Vascular) in the right common iliac scans showed stability. However, in 2021, 7 years later, a type Ib artery. endoleak from both iliac arteries and an increase in the aortic Two years after the last surgery, in 2013, progressive aneurysmal diameter to 109 mm were detected (Fig 2). At that time, 10 years degeneration was noted, due to a distal endoleak. First, the after the first intervention, our patient was 67 years old. Total proximal anastomosis of the visceral debranching bypass was reconversion to open surgery was not considered because of redone distally at the iliac bifurcation to cover the left common the multiple reinterventions, hostile abdomen, and high risk of iliac artery. Next, we placed bifurcated Endurant II 36  16  166- visceral bypass complications. In addition, the patient was reluc- mm and 16  24  124-mm endografts (Medtronic Vascular) tant to undergo another open surgery. overlapped with the previous endograft to both iliac bifurca- We planned a three-stage surgery to repair the type Ib endo- tions. During this procedure, the bypass branch to the hepatic leak. First, through a right femoral percutaneous access, the artery thrombosed and required thrombectomy and stenting left hypogastric artery was embolized with coils (Ruby System; (Fig 1). After this surgery, the patient suffered splenic bleeding Penumbra, Alameda, CA). Second, a 13  50-mm Viabahn stent with hypovolemic shock that required splenectomy and graft (W.L. Gore & Associates, Flagstaff, AZ) was deployed in the Journal of Vascular Surgery Cases, Innovations and Techniques Tello-Díaz et al 3 Volume 9, Number 2 Fig 2. Computed tomography reconstructions evidencing type Ib endoleak through both common iliac ar- teries. A, Anteroposterior projection. B, Lateral projection showing the relationship with visceral debranching. right external iliac artery to cover the right hypogastric artery, DISCUSSION and femorofemoral bypass (right to left) with an 8- We present the complex repair of a type Ib endoleak in mmpolytetrafluoroethylene graft (W.L. Gore & Associates) was a patient with multiple interventions for cTBAD. The type performed. Finally, through a left retroperitoneal approach, a Ib endoleak was treated with a hybrid solution that 10-mm Dacron graft (Maquet) was sutured to the previous included off-label placement of a thoracic endovascular visceral debranching (right renal artery branch) for endovascular graft inside a visceral debranching graft. cannulation. Through this Dacron conduit and right brachial ar- The management of cTBAD remains controversial. The tery access, a “through and through” was performed, allowing us INSTEAD (investigation of stent grafts in patients with to place a 20F, 65-cm DrySeal Flex sheath (W.L. Gore & Associ- type B aortic dissection) trial revealed no advantages of ates) in the aorta across the previous debranching. A 28  thoracic endovascular repair (TEVAR) compared with 28  150 cTAG conformable endograft (W.L. Gore & Associates) medical therapy at 2 years.4 Surgical treatment is justi- was placed from the left common iliac artery to the visceral fied when aneurysmal degeneration (30%),5 rapid aortic debranching graft, leaving the thoracic stent graft with a 180 growth, or symptoms are detected during follow-up. curve (Fig 3). Completion arteriography revealed correct deploy- cTBAD with a descending thoracic aortic diameter ment of the endograft, with a small residual type Ib endoleak. >55 mm should be considered for treatment owing to The Dacron conduit was removed without incident. The postop- the increased ruptured risk.3 erative course was uneventful with patent femorofemoral and Open surgery has provided good results but with high visceral bypasses. The patient was discharged on the fourth morbidity.6,7 Hybrid approaches (visceral debranching postoperative day. and aortic endografting) allow for treatment of TBADs, One year after surgery, the patient was doing well and was able avoiding extensive aortic exposure and total clamping to resume his daily activities without any limitations. A 9-month of the aorta and allowing for circulatory support. Thus, follow-up computed tomography angiography scan demon- they are considered less invasive, although they could strated no evidence of type I endoleaks (Fig 4), patency of the also be indicated for patients with low comorbidities.6 visceral debranching and thoracic endovascular graft with a At present, open surgery is being replaced by endovas- 180 curved shape, a decreased diameter of the right iliac artery, cular treatment, even without data from randomized and stability of the aortic diameter. studies.8 Good early and long-term outcomes have 4 Tello-Díaz et al Journal of Vascular Surgery Cases, Innovations and Techniques June 2023 Fig 3. Fluoroscopy images showing placement of the cTAG endograft from the common iliac artery to the visceral debranching graft, acquiring a 180 curved shape. A, Placement inside the visceral debranching. B, Image after device release. C, Image after balloon dilation of the prosthesis. Fig 4. Computed tomography reconstructions showing endograft placement, with a 180 curved shape within the visceral debranching Dacron graft without kinking or endoleaks. been reported for endovascular strategies to treat Endovascular treatment aims to prevent persistent cTBAD, especially for unfit patients.9,10 In 2013, Nienaber perfusion of the false lumen to obtain a reduction in et al8 reported the benefits in terms of survival of pre- the aortic diameter.1,11 TEVAR in the chronic phase of emptive TEVAR, in addition to medical treatment, for TBAD can be challenging and often requires extensive patients with TBAD. aortic coverage.3,11,12 The flap stiffness in this chronic Journal of Vascular Surgery Cases, Innovations and Techniques Tello-Díaz et al 5 Volume 9, Number 2 stage and the lack of remodeling implies that reinterven- thoracic aorta diseases: clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg tions will be frequent (18%-50%).13,14 2017;53:4-52. Often, using TEVAR alone will not be enough to achieve 4. Nienaber CA, Rousseau H, Eggebrecht H, Kische S, Fattori R, aortic remodeling owing to persistent false lumen filling. Rehders TC, et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt grafts in aortic dissection Many adjuvant techniques to TEVAR have been (INSTEAD) trial. Circulation 2009;120:2519-28. described, most of which are off label.15 The aim could 5. Song JM, Kim SD, Kim JH, Kim MJ, Kang DH, Seo JB, et al. Long-term be to occlude the false lumen, such as the Knickerbocker predictors of descending aorta aneurysmal change in patients with aortic dissection. J Am Coll Cardiol 2007;50:799-804. and candy plug techniques.16-18 In addition, new fenes- 6. Damrauer SM, Fairman RM. Visceral debranching for the treatment trations have been performed in the false lumen to com- of thoracoabdominal aortic aneurysms. Aorta 2015;3:67-74. plete an endovascular treatment.19 Thus, for cTBAD, 7. Roselli EE. Thoracic endovascular aortic repair versus open surgery for type-B chronic dissection. J Thorac Cardiovasc Surg 2015;149: some novel techniques have been used to increase the S163-7. benefits of this endovascular approach. 8. Nienaber CA, Kische S, Rousseau H, Eggebrecht H, Rehders TC, We have described the case of a patient with cTBAD, Kundt G, et al. Endovascular repair of type B aortic dissection: long- term results of the randomized investigation of stent grafts in aortic who had initially been treated with a hybrid approach dissection trial. Circ Cardiovasc Interv 2013;6:407-16. owing to his good physical condition but who had un- 9. Spanos K, Kölbel T. Role of Endoluminal techniques in the man- dergone multiple reinterventions because of the devel- agement of chronic type B aortic dissection. Cardiovasc Intervent Radiol 2020;43:1808-20. opment of distal endoleaks filling the false lumen. 10. Spear R, Sobocinski J, Settembre N, Tyrrell MR, Malikov S, Maurel B, When he presented yet again with an endoleak but et al. Early Experience of endovascular repair of Post-dissection an- was considered at high risk of multiple complications eurysms involving the thoraco-abdominal aorta and the Arch. Eur J Vasc Endovasc Surg 2016;51:488-97. owing to the hostile abdomen, complete conversion to 11. Thrumurthy SG, Karthikesalingam A, Patterson BO, Holt PJE, open surgery was not considered. We proposed an endo- Hinchliffe RJ, Loftus IM, et al. A systematic review of mid-term out- vascular solution with placement of a thoracic endograft comes of Thoracic Endovascular Repair (TEVAR) of chronic type B aortic dissection. Eur J Vasc Endovasc Surg 2011;42:632-47. inside a Dacron graft, with a 180 curve, pushing the ca- 12. Hamady M, Bicknell C. Challenges of total endovascular repair of pabilities of the endovascular grafts to the limit. We chronic type B aortic dissection. Cardiovasc Intervent Radiol 2020;43: chose the cTAG conformable endograft (W.L. Gore & As- 1735-7. 13. Scali ST, Feezor RJ, Chang CK, Stone DH, Hess PJ, Martin TD, et al. sociates) because of its great flexibility. The thoracic graft Efficacy of thoracic endovascular stent repair for chronic type B showed great adaptation to the shape of the Dacron aortic dissection with aneurysmal degeneration. J Vasc Surg 2013;58: graft without kinking. 10-7.e1. 14. Manning BJ, Dias N, Ohrlander T, Malina M, Sonesson B, Resch T, et al. CONCLUSIONS Endovascular treatment for chronic type B dissection: Limitations of short stent-grafts revealed at midterm follow-up. 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