PMC5956622_01
Pre-operative computed tomography. (A) Three dimensional images, in the antero-posterior (AP) and postero-anterior (PA) views, showed a post-dissection thoraco-abdominal aortic aneurysm. The arrows indicate re-entry tears at the detached right lumbar arteries in the PA view. (B) A haematoma around a dilated descending false lumen indicates rupture (arrow). In the right thorax, there was a large chronic empyema (arrowhead). (C) A multiplanar reconstruction image showed a large re-entry tear at the detached right renal artery ostium (arrow). (D) Another major re-entry tear at the right iliac bifurcation (arrow).
gr1.jpg
PMC5956622_01_gr1.jpg
fig1
Contrast enhanced computed tomography (CECT) showed aortic dissection extending from the distal aortic arch to the right external iliac artery (Fig. 1A). There was a haematoma around a dilated lower descending aorta, measuring 55 mm in diameter (Fig. 1B). Multiplanar reconstruction images showed multiple re-entries at the detached right RA (Fig. 1C) and right lumbar arteries (Fig. 1A), and the right iliac bifurcation (Fig. 1D).
Multiple re-entry closures using aortic and branch endografts following TEVAR. Dots indicate the sites of re-entry tear. (A) After TEVAR, abdominal true lumen aortography showed marked ascending blood flow in the thoraco-abdominal false lumen (FL; arrows). (B) Re-entry at the detached right renal artery (RA) ostium (white dot) was closed using a covered stent. Re-entries at the detached right lumbar arteries (black dots) were closed by endovascular aneurysm repair, and both RAs were spared using the chimney technique. (C) Re-entry at the right iliac bifurcation (white dot) was closed by an iliac extender (arrow). (D) Two aortic extenders (arrows) were placed to close re-entries at the ostia of the detached bilateral inferior phrenic and left twelfth intercostal arteries (black dots) above the coeliac artery. (E) Completion aortography showed remaining FL retrograde flow from the re-entry at the ostium of the detached right first lumbar artery located between the coeliac and superior mesenteric artery (SMA), but it was significantly diminished (arrows). (F) Post-procedural three dimensional computed tomography (without contrast enhancement) shows all deployed endografts and the endovascular procedures that were performed.
gr2.jpg
PMC5956622_01_gr2.jpg
fig2
Associates, Flagstaff, AZ, USA) via left femoral access. The left subclavian artery was covered without revascularisation. After TEVAR, abdominal TL aortography showed marked retrograde blood flow in the thoraco-abdominal FL (Fig. 2A). Both RAs were spared using the chimney technique (Fig. 2B). Another major re-entry at the right iliac bifurcation was closed by adding a 7 cm iliac extender (Fig. 2C). Furthermore, two aortic extenders (26 mm x 3.3 cm and 23 mm x 3.3 cm, respectively) were placed to close the remaining re-entries above the coeliac artery (Fig. 2D). Although residual FL flow from the re-entry between coeliac and SMA level was still seen on angiography, it was significantly diminished compared with that seen on pre-procedural angiography (Fig. 2E).
Computed tomography images (A-C) 3 days and (D) 4 months after thoraco-abdominal aortic aneurysm repair. (A, B) A patent thoracic false lumen (FL) was completely thrombosed (arrows), including the rupture site (arrowhead). (C) Coeliac level. Although the FL was not thrombosed (arrows), significant FL shrinkage was obtained. (D) After 4 months, further shrinkage of the thoracic FL was observed compared with the previous image at the same section B. The true lumen was fully expanded (arrows).
gr3.jpg
PMC5956622_01_gr3.jpg
fig3
CECT 3 days after the operation showed that the thoracic FL, including the rupture site, was completely thrombosed (Fig. 3A, B). Although some FL flow remained, it was limited to coeliac level, and the FL had already shrunk (Fig. 3C). After 4 months, further FL shrinkage was observed (Fig. 3D).