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Menaka Nadar, MD
University of Virginia
CC: Acute onset abdominal pain
HPI: 43 year old male with a history of Marfan’s
syndrome presented to outside hospital with
acute onset abdominal pain. Transferred for
further evaluation after CTA demonstrated acute
aortic dissection extending from the left
subclavian artery to the left common iliac artery.
PMH
• Marfan’s syndrome
PSH
• Aortic root repair
and mechanical AVR
for type A aortic
dissection in 2007
• Pacemaker
placement
Medications
• Coumadin for
mechanical valve
– INR 3.1 on admission
Allergies
• None
Imaging
• Dissection flap involving the left subclavian
artery
• Multiple supraceliac fenestrations
• Right renal artery from true lumen
• Left renal artery from false lumen
• Celiac artery, SMA, and IMA off true lumen
• Narrowing of true lumen due to
compression by false lumen
• Severe focal narrowing of left common
iliac artery
Diagnosis/Discussion
• 43 year old male with Marfan’s syndrome and
acute type B dissection
– Dissection flap involves left subclavian artery and
left common iliac artery
– All visceral vessels except left renal artery
originate from true lumen
– Narrowing of true lumen by compression from
false lumen
– No evidence of end organ ischemia
Potential Complications
•
•
•
•
•
•
•
•
Paraplegia
Stroke
Mesenteric ischemia
Left upper/lower extremity ischemia
Endoleak
Stent migration
Bleeding (anticoagulated on admission)
Mechanical valve thrombus/thromboembolic
event (off full anticoagulation periprocedure)
Intervention
•
•
Left carotid to subclavian bypass
Thoracic endovascular stent graft x 2
beginning just distal to the left common
carotid
• Abdominal endovascular stent graft
• Left common iliac artery stent
• Post-procedure day 1
patient complained of
left leg paresthesias.
• PVRs showed biphasic
waveforms bilaterally.
ABIs: 0.62 on the right,
0.7 on the left.
• CTA showed increased
narrowing of the true
lumen adjacent to the
visceral vessels.
On postprocedure day 3, IVUS used to advance needle from true
lumen into false lumen to create fenestration in dissection flap.
Balloon dilatation of fenestration with equal pressures within false
and true lumens post procedure. Left leg paresthesias resolved.
Summary
• 43 year old male with Marfan’s syndrome presents
with acute aortic dissection from the left subclavian
artery to the left common iliac artery with all visceral
vessels except left renal artery from narrowed true
lumen.
• Treated with thoracic and abdominal endografts, left
common iliac stenting, and left carotid-subclavian
bypass.
• Postprocedure developed left leg paresthesias,
worsened narrowing of true lumen, and decreased
ABIs, treated with fenestration of the dissection flap.