Case Report
An 83-year-old man presented with acute-onset abdominal pain. Computed
tomography (CT) revealed TAAD with primary entry tear at the distal
aortic arch and compression of the TL by the FL in the superior
mesenteric artery (SMA) with dilated and fluid-filled small bowel loops
(Figure 1). Thus, the diagnosis was TAAD, complicated by mesenteric
malperfusion. We decided to reperfuse the visceral organs before central
aortic repair.
An emergency surgery was performed under general anesthesia. Laparotomy
was performed, and a pulseless SMA and small bowel ischemia were
identified. Under fluoroscopic guidance, a 10-mm stent (SMART; Cordis
Corp., Miami Lakes, FL, USA) was deployed at the ostium of the SMA in a
retrograde fashion through the 6 Fr sheath inserted from the branch of
the SMA, which was then connected to the femoral artery sheath, which
served as an external shunt. Thereafter, total arch repair with FET,
“Zone 0 arch repair strategy,1” was performed using
a FET graft and a 4-branched graft (35 mm × 150 mm J Graft FROZENIX and
28 mm J Graft SHIELD, respectively; Japan Lifeline Co. Ltd., Tokyo,
Japan). A primary entry tear was identified in the distal aortic arch
(Figure 2A). The FET graft was carefully inserted into the descending
aorta under direct vision. After weaning from cardiopulmonary bypass
(CPB), the SMA remained pulseless. In addition, transesophageal
echocardiography (TEE) showed expansion of the FL in the descending
aorta distal to the FET graft, suggesting malposition of the FET into
the FL of the descending aorta (Figure 2B). Thereafter, malposition of
the FET was confirmed using intravascular ultrasound (IVUS).
Percutaneous fenestration of the dissecting flap and endograft
deployment from the inside of the malpositioned FET to the TL of the
descending aorta were subsequently performed. Under IVUS and
fluoroscopic guidance, an angled 5-Fr catheter (Impress Diagnostic
Peripheral catheter; Merit Medical, South Jourdan, UT, USA) was rotated
and its tip was positioned against the center of the dissecting flap.
Then the dissecting flap, 4 cm distal to the distal end of the FET, was
perforated using a 0.014-inch tapered tip microguidewire (Chevalier14
Tapered 30; FMD Co., Ltd, Tokyo, Japan) by a quick, short thrust. The
outer catheter was advanced over the microguidewire from the TL to the
FL of the descending aorta. Thereafter, a 0.035-inch extra-stiff
guidewire (Lunderquist; Cook Medical Inc., Bloomington, IN, USA) was
reintroduced through the outer catheter, and a stiff guidewire was
placed across the dissecting flap to the inside of the FET (Figure
2D/E/F). A tapered 38/34 mm × 190 mm endograft (Relay Plus; Bolton
Medical, Sunrise, FL, USA) was deployed from the inside of the FET to
the TL of the descending aorta. Subsequent aortography showed no
endoleak, and IVUS revealed good expansion of the endograft and the TL
of the downstream aorta. SMA pulsation and bowel peristalsis returned
after endograft deployment. Postoperative complications related to
aortic or visceral malperfusion were not observed. Follow-up CT revealed
a patent endograft and expansion of the TL of the downstream aorta
without SMA stenosis (Figure 3).