Hybrid Staged Repair of Complex Chronic Type B Aortic Dissection with Open Infrarenal Aortic Repair and TEVAR for Patients with Extensive Iliac Involvement: Report of Two Cases

Abstract

<h3>Introduction and Objective</h3> Chronic thoracoabdominal aortic dissections are often complicated by aneurysms or occlusions with extensive aortic and iliac involvement requiring complex repair. A hybrid and staged approach to aortic and iliac repair limiting supraceliac clamp time may lead to improved outcomes. We report our experience with this approach in two patients. <h3>Methods</h3> Between March 2020-2021, we treated two patients with complex chronic type B aortic dissection with involvement of the entire descending aorta with extension to the iliac arteries. One patient had a distal aortic and iliac occlusion secondary to his chronic dissection, the other patient had an infrarenal AAA > 5.5 cm and a common iliac artery aneurysm. Both patients were managed with infrarenal aortic repair using aortobi-iliac graft to treat the infrarenal aortic and iliac pathology. The thoracic aortic pathology was managed with TEVAR and a left carotid-subclavian bypass. The mesenteric portion of the aorta was treated with open fenestration in one patient and was left untreated in one patient. <h3>Results</h3> Both patients underwent successful staged hybrid repair of extensive complicated chronic type B aortic dissection without stroke, spinal cord injury or death, one patient has undergone further thoracic stenting for management of a stent-graft induced entry tear (SINE). <h3>Conclusion</h3> Management of complicated chronic type B aortic dissection with distal aortic and iliac occlusion or aneurysm is challenging. The infrarenal aorta and iliacs are important to maintain spinal collaterals through the hypogastric arteries and to allow delivery of endovascular devices for thoracic and/or fenestrated aortic repair. Staged hybrid repair of complicated type B aortic dissection with avoidance of supraceliac clamp time may improve outcomes.