PMC10196481_01
(A, B) Initial contrast-enhanced computed tomography (CECT) of the neck and chest in two consecutive coronal sections show an aortic dissection (asterisk) with innominate artery (IA) extension (single solid arrow). At this point, the main IA trunk remained patent without flow-limiting stenosis (single dashed arrow). (C, D) Coronal (C) and axial (D) images of CECT two days following ascending aortic grafting show expansion of the dissection's false lumen (double solid arrows), the distal extension of the dissection involving common carotid artery (triple solid arrows) and subclavian artery (double dashed arrows), and nearly complete occlusion of the main IA trunk and its bifurcation. (E, F) Diffusion-weighted imaging and arterial spin labeling perfusion magnetic resonance imaging of the brain reveal few embolic spots (E) associated with a large hypoperfusion in the right hemisphere (F).
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F1
Whole body contrast-enhanced computed tomography (CECT) revealed an aortic dissection extending from the ascending to the descending aorta, which also involved the IA and extended into the right common carotid artery (CCA) (Figures 1A, B). CECT of the neck revealed a progression of the IA dissection, tight narrowing of the residual IA true lumen, and involvement of the right CCA and subclavian artery (SA) orifices (Figures 1C, D). Perfusion magnetic resonance imaging of the brain showed marked right-sided hemispheric hypoperfusion (Figures 1E, F).
Four proposed treatment strategies (A-D) for kissing stent placements based on different accesses (trans-femoral, trans-brachial, or trans-carotid access) and different approaches (endovascular or a combined endovascular and open approach). Check-sign (with green circle background) and cross-sign (with red circle background) indicate the pros and cons, respectively, of the corresponding choice. Notice that strategy A and B have 1 pro and 3 cons, strategy C has 3 pros and 1 con, and strategy D has 4 pros and 0 cons. Solid arrow represents the direction of endovascular procedure in innominate artery (IA) to common carotid artery (CCA) stenting strategy. Dashed arrow represents the direction of endovascular procedure in IA to subclavian (SA) stenting strategy.
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F2
After comparing the pros and cons of four kissing stent reconstruction strategies (Figure 2) designed based on different approaches (endovascular or a combined endovascular and open approach) and different accesses (trans-femoral, trans-brachial, or trans-carotid access), we chose a combined open and endovascular approach (Strategy D in Figure 2) for the lesion because it could provide better guiding catheter support for the endovascular procedures and prevent peri-procedural cerebral emboli.
(A) Intra-innominate artery (IA) angiogram obtained from a transfemoral-placed angiocatheter reveals tight stenosis of the IA true lumen (double solid arrows) and compromised flow to the common carotid artery (CCA, single solid arrow) and subclavian artery (SA, single dashed arrow). (B) Fluoroscopic snapshot of the middle part of the kissing stenting procedure reveals simultaneous retrograde deployment of two Wallstents via a trans-brachial (single arrowhead) and a trans-carotid (double arrowheads) access. Also, notice the distal CCA clamp (asterisk) used for cerebral embolic protection during balloon angioplasty and stent deployment. (C, D) Following IA recanalization, both catheter angiography (C) and axial contrast-enhanced computed tomography (D) confirm good opening and apposition of both stents [curved arrow in (D)] and successful CCA (solid arrow) and SA (dashed arrow) recanalization (C). (E, F) Diffusion-weighted imaging and arterial spin labeling perfusion magnetic resonance imaging of the brain show no increase in embolic spots (E) and symmetric hemispheric perfusion (F).
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F3
A roadmap of the target lesion, together with the CCA and SA, was obtained using a 5F H1 diagnostic angiocatheter placed via trans-femoral access, with its tip in the IA orifice (Figure 3A). Through both microwires, two 7 x 50-mm Wallstents (Boston Scientific) were then simultaneously deployed in parallel from the IA to CCA and from the IA to SA (Figure 3B). A final angiography and CECT showed the patent stents and successful CCA and SA reperfusion (Figures 3C, D). The patient also regained consciousness, and postoperative perfusion brain magnetic resonance imaging showed symmetric cerebral perfusion without new ischemic stroke (Figures 3E, F).