Endovascular Approach to Severe Acute Type B Aortic Dissection

Abstract

Acute aortic dissection (AAD) is an important emergency that should be identified promptly. The classification of AAD follows two different systems: Stanford (which defines lesions as types A, on the ascending aorta, or B, on the descending aorta) and DeBakey, which also accounts for the extension of the aortic dissection. We present a notable case of a 63-year-old male who presented with a history of abrupt abdominal pain radiating to the dorsal region for endovascular treatment. He was oliguric with symmetric pulses in the superior limbs and reduction of pulses in the left lower limbs, with signs of hypoperfusion. Angiotomography evidenced acute abdominal thoracic aortic dissection classified as DeBakey III and Stanford B, extending through the left iliac artery. He was submitted to endovascular correction of the abdominal thoracic aortic dissection, with implantation of two straight Valiant type endoprosthesis (26x200 mm and 38x200 mm), positioned after the emergence of the left subclavian artery and right above the celiac trunk, respectively. There was also implantation of the stent graft Viabahn (5x60 mm) and Assurant stent (7x30 mm) in the left renal artery. After the urgent surgical intervention, the patient has recovered well. He has been checked in outpatient follow-ups for the past three years with preserved renal function (1.5 mg/dl creatinine) and correct positioning of the endoprosthesis (confirmed by CT without contrast). Hypertension and a smoking history are the most important risk factors associated with aortic dissections, and should be considered when evaluating a patient with chest or back pain (typically described as sharp rather than tearing or ripping) in the emergency department. The endovascular approach to descending dissections was introduced in 1999 and has been established as the standard approach to descending dissections of the aorta, because of the excess mortality of the open approach (32% in open surgery and 7% for those managed with endovascular techniques) and low rate of complications. Ten-year survival rates for patients with AAD ranging from 30% to 60% justifies an aggressive follow-up strategy of discharge, with the goal of minimizing aortic wall stress through drugs (such as β blockers) and surveillance to detect progression. Our report shows that an early detection of symptoms coupled with an aggressive and precise endovascular intervention has produced satisfactory clinical, laboratorial and quality-of-life outcomes in an older patient with an extensive type B arterial dissection.