Hybrid approach for management of type B dissection involving the aortic arch

Acute type B aortic dissections can be treated medically, surgically as well as by thoracic endovascular stents (TEVAR). However, presentations and pathology can vary and an isolated strategy may not be adequate in managing the condition satisfactorily. We describe a hybrid approach using surgery and endovascular stents to adequately manage type B dissection in a 76-year-old man, a known hypertensive and chronic smoker who presented to the emergency department with acute retrosternal pain radiating to the neck and back. The patient had intractable pain and refractory hypertension despite optimal medical therapy. Echocardiography showed a large subclavian atheromatous flap. Computed tomography (CT) scan confirmed type B aortic dissection (Fig. 1). In view of the patient being elderly, hypertensive and a chronic heavy smoker, surgical repair was considered to be associated with high risk. As the pathology extended up to the left subclavian artery, endovascular stent placement with a sufficient landing zone would have required occlusion of the left carotid artery. A decision was therefore taken to perform a carotico-carotid bypass and an endovascular stent to treat the type B aortic dissection.
The carotico-carotid bypass preceded the endovascular stent placement. End-to-side 8 mm PTFE grafts were anastomosed to the right and left carotid artery using 6-0 prolene suture with partial cross clamp. Neurological status was monitored throughout the procedure with the Symantec monitoring system. Following the completion of the carotico-carotid bypass the left subclavian artery was coiled with 1 × 20 mm × 8 cm and 2 × 14 mm × 8 cm Nestor coils to prevent future leaks. A Cook Zenith TX -2 thoracic endograft (36/20-2 mm) was implanted in the descending thoracic aorta with the proximal landing zone extending to the origin of the left subclavian artery. Procedural CT angio showed a satisfactory position of the endovascular stent and no endoleaks. Also the carotico-carotid bypass was confirmed to be patent (Fig. 2).
The patient was extubated on the first postoperative day (POD) without any neurologic deficit. The postoperative course was uneventful and the patient was discharged from the hospital in a stable and improving condition. At 6 months follow-up the patient remains well with no neurological deficits.
Surgical repair of acute type B aortic dissection is associated with higher mortality compared to TEVAR (17.5% vs. 10.2%) especially in the...


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