VS2. Open Repair of Distal Aortic Failure Following TEVAR for Type B Aortic Dissection

Abstract

This case illustrates the management of distal aortic failure following previous proximal thoracic endovascular aortic repair (TEVAR) for type B aortic dissection via an open approach. The patient is a 59-year-old woman with chronic hypertension and multiple previous aortic interventions, including ascending and arch repair related to acute intramural hematoma. After many years of stability, she developed an acute type B dissection distal to her previous repair with right lower extremity malperfusion and was treated with TEVAR. On routine surveillance imaging, a 7.2-cm type V thoracoabdominal aneurysm distal to her stent grafts rapidly developed due to a new entry tear. Her anatomy was not suitable for Food and Drug Administration-approved endovascular therapy. After extensive counseling discussing the risks and benefits, she elected to proceed with definitive open aortic reconstruction. Our standard thoracoabdominal incision was made, and the aorta was exposed via retroperitoneal approach. The left inferior pulmonary vein and left femoral artery were cannulated to provide partial heart bypass and distal perfusion. The aorta was doubly clamped, and an aortotomy was made and extended appropriately, exposing the distal extent of the previous TEVAR. The distal portion of the TEVAR was resected, and reconstruction was performed using a Dacron graft. The proximal anastomosis was incorporated into the remaining distal TEVAR graft, and a beveled distal anastomosis was fashioned to the visceral aortic segment. The left renal artery was reimplanted as a Carell patch. The patient tolerated the procedure well, aside from brief need for hemodialysis therapy. By postoperative day 7, the patient had returned to her baseline renal function. She was discharged to a rehabilitation facility on postoperative day 12 for further convalescence.