PMC3971851_01
(a) Preoperative axial contrast-enhanced CT chest showing intimomedial flap in the aortic arch (black arrow) and partially thrombosed aneurysmal false lumen (white arrow). (b) CT angiogram, volume-rendered 3D image showing residual aortic arch and descending aortic dissection with aneurysmal degeneration (black arrow) following prior graft replacement of ascending aorta (white arrow) for type A aortic dissection.
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CT angiogram revealed patent mid ascending aortic prosthetic graft with native aortic root and normal coronaries, with dissection flap noted in the arch (Figure 1(a)) and descending aorta extending across the abdominal aorta up to the bifurcation of right common iliac artery (Figure 1(b)).
(a) Digital subtraction angiogram prior to stent graft deployment showing patent grafts taking inflow from previously placed ascending aortic graft with 10 mm graft to left common carotid artery (black arrow), piggybacking an 8 mm graft to left common carotid artery (white arrow), and another 8 mm graft to left subclavian artery (red arrow). The native stumps of the debranched arch vessels are also seen (blue arrow). (b) Check angiogram after stent graft deployment showing opened-up true lumen and nonopacification of false lumen. (c) CT angiogram, volume-rendered 3D image at 1 year follow-up showing patent bypass grafts, significantly remodelled aorta, and near-total thrombosis of false lumen.
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Debranching of the arch vessels was undertaken as 1st stage of the hybrid repair using a 10 mm knitted bovine gelatin coated polyester graft (Uni-graft K DV, Braun Aesculap, Tuttlingen, Germany) for bypass from ascending aortic prosthesis to the right common carotid artery, piggybacking 8 mm grafts to left common carotid artery and left subclavian artery (Figure 2(a)). On recovery endorepair was accomplished by deployment of 36 x 200 mm Valiant Thoracic Captivia aortic stent graft (Medtronic Inc., Minneapolis, MN, USA) from within the distal ascending aortic prosthetic graft across the debranched arch up to mid DTA, confirming nonopacification of false lumen on check angiogram (Figure 2(b)). At 1 year follow-up he remains symptom free and active, with CT angiogram showing patent bypass grafts, significantly remodelled aorta, and near-total thrombosis of false lumen (Figure 2(c)).