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).