Endovascular Repair of a Complicated Acute Type B Aortic Dissection Using a Combination of the STABILISE and CERAB Techniques

Abstract

Introduction: Endovascular treatment of type B aortic dissection has focused on covering the proximal entry tear. However, recently, concern has emerged regarding the distal aortic remodeling and new techniques such as the Stent-Assisted Balloon-Induced Intimal Disruption and Relamination (STABILISE) technique have gained acceptance. We describe a case report in which the STABILISE technique was used in addition with the Covered Reconstruction of the Aortic Bifurcation (CERAB) technique for complete aortic remodeling. Methods: Clinical data were collected from the hospital's records. Results: A 34-year-old male, with a history of hypertension was admitted at the emergency department for acute-onset back pain, severe hypertension and right lower limb ischemia. A CT-Angiography confirmed a type B aortic dissection with true lumen compression and right common iliac artery occlusion. At first, blood pressure and pain were controlled with IV drugs, however the lower limb ischemia persisted. A plan was made to first treat the limb ischemia and delay the aortic repair for the sub-acute phase, if necessary. A common iliac artery kissing stent was performed using Atrium Advanta V12® (10mm) stents and a self-expandable uncovered stent to the external iliac on the right side. The patient recovered well, however, 5 days later, refractory chest pain and hypertension developed. A CT-Angiography showed severe true lumen compression at the visceral aorta and we decided to perform an urgent repair of the aortic dissection. After true lumen catheterization, a TEVAR was performed landing over the left subclavian artery (COOK®ZTA P-32-201) followed by deployment of a bare-metal dissection stent ending 2 cm below the renal arteries (COOK®ZDES 36-180). A control angiography showed false lumen exclusion at the proximal aorta, however the distal aortic true lumen was still severely compressed. For that reason, a STABILISE was performed using a non-compliant 28mm balloon proximally and a 23mm balloon distally. Because the true lumen was still compressed at the infra-renal aorta, we decided to proceed with a CERAB technique, using a Bentley® Aortic BeGraft (18x48mm) deployed just distal to the renal arteries. Proximal flaring of the stent was performed using the 23mm non-compliant balloon. Two 10x59mm Atrium Advanta® V12 stents were used for the iliac extensions ending inside the previous iliac kissing stents. Angiographic control was optimal, and the patient recovered well. However, the patient was still dependent on 4 oral anti-hypertensive drugs, so a new CT-Angiography was performed and showed an intimal flap inside the right renal artery. Under local anesthesia, a Cordis® Palmaz Blue (6x18mm) stent was deployed in the right renal artery through the aortic dissection stent. The patient was latter discharged with adequate hypertension control under two oral anti-hypertensive drugs and the control CT one month after treatment showed complete remodeling of the aorta and perfusion of all visceral branches. Conclusion: We report a case of a combination of the STABILISE and CERAB techniques used to treat an acute type B aortic dissection. This combination allowed for a covering of both the entry tear and the distal re-entry tears resulting in a complete flap apposition, false lumen obliteration and optimal remodeling. Disclosure: Nothing to disclose