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Aortic Fenestration: A Why, When, and How-to Guide¹

¹ From the Department of Radiology, Tufts University School of Medicine, Baystate Medical Center, 749 Chestnut St, Springfield, MA 01199. Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received April 19, 2004; revision requested June 2 and received July 19; accepted July 22. Both authors have no financial relationships to disclose. Address correspondence to G.G.H. (e-mail: george.hartnell@bhs.org).

View larger version (133K): [in a new window]   Figure 1a.  Aortic dissection in a patient who presented with severe chest, abdominal, and lower extremity pain with no palpable femoral pulses. The patient had recently undergone aortic valve replacement and coronary artery bypass surgery. (a) CT scan shows a type A dissection extending to the aortic bifurcation. There is narrowing of the true lumen of the aorta at the level of the renal arteries, with the left renal artery (arrow) arising from the false lumen (F). (b) CT scan obtained inferior to a shows the true lumen of the aorta compressed to a slit (arrow) by the nonenhanced but hypertensive false lumen (F). A horseshoe kidney is also seen (*). It was felt that the risk posed by further aortic surgery was too high, and fenestration was requested to restore lower extremity circulation. (c) Pelvic arteriogram obtained with access from the right femoral artery shows significant obstruction at the lower aorta, as predicted from the CT scans (cf a, b). (d) Aortogram shows two right renal arteries arising from the true lumen, with severe narrowing of the infrarenal aorta (arrows). (e) Intravascular ultrasonographic (US) image helps confirm that access was into the true lumen and that there was adequate space to puncture the center of the flap (arrows), with over 1 cm of false lumen depth (*) beyond the flap. (f) Digital image shows a Rösch-Uchida needle (Cook, Bloomington, Ind) (arrow) that was inserted to the level of the intravascular US transducer (arrowhead). Intravascular US was used to guide the puncture. (g) Intravascular US image shows the needle tip (arrow) in the middle of the flap. (h) Intravascular US image demonstrates a balloon (arrows) that has been dilated to 18 mm and is correctly positioned; as a result, the pressures in the true and false lumina were equalized. (i) Aortogram shows filling of the left renal artery from the false lumen (arrow), with persistent narrowing of the lower aorta in spite of balloon angioplasty. (j) Aortogram shows coaxial deployment of two of the largest stents available at that time (20 x 40 Wallstents; Boston Scientific, Natick, Mass) within the true lumen (arrowheads) and below the upper left renal artery origin (arrow). The procedure was successful in preventing recoil of the obstruction, and there was no significant pressure gradient. Following this procedure, the patient’s lower extremity rest pain resolved and his femoral and distal pulses returned (there was no infrainguinal obstructive disease).

View larger version (133K): [in a new window]   Figure 1b.  Aortic dissection in a patient who presented with severe chest, abdominal, and lower extremity pain with no palpable femoral pulses. The patient had recently undergone aortic valve replacement and coronary artery bypass surgery. (a) CT scan shows a type A dissection extending to the aortic bifurcation. There is narrowing of the true lumen of the aorta at the level of the renal arteries, with the left renal artery (arrow) arising from the false lumen (F). (b) CT scan obtained inferior to a shows the true lumen of the aorta compressed to a slit (arrow) by the nonenhanced but hypertensive false lumen (F). A horseshoe kidney is also seen (*). It was felt that the risk posed by further aortic surgery was too high, and fenestration was requested to restore lower extremity circulation. (c) Pelvic arteriogram obtained with access from the right femoral artery shows significant obstruction at the lower aorta, as predicted from the CT scans (cf a, b). (d) Aortogram shows two right renal arteries arising from the true lumen, with severe narrowing of the infrarenal aorta (arrows). (e) Intravascular ultrasonographic (US) image helps confirm that access was into the true lumen and that there was adequate space to puncture the center of the flap (arrows), with over 1 cm of false lumen depth (*) beyond the flap. (f) Digital image shows a Rösch-Uchida needle (Cook, Bloomington, Ind) (arrow) that was inserted to the level of the intravascular US transducer (arrowhead). Intravascular US was used to guide the puncture. (g) Intravascular US image shows the needle tip (arrow) in the middle of the flap. (h) Intravascular US image demonstrates a balloon (arrows) that has been dilated to 18 mm and is correctly positioned; as a result, the pressures in the true and false lumina were equalized. (i) Aortogram shows filling of the left renal artery from the false lumen (arrow), with persistent narrowing of the lower aorta in spite of balloon angioplasty. (j) Aortogram shows coaxial deployment of two of the largest stents available at that time (20 x 40 Wallstents; Boston Scientific, Natick, Mass) within the true lumen (arrowheads) and below the upper left renal artery origin (arrow). The procedure was successful in preventing recoil of the obstruction, and there was no significant pressure gradient. Following this procedure, the patient’s lower extremity rest pain resolved and his femoral and distal pulses returned (there was no infrainguinal obstructive disease).

View larger version (154K): [in a new window]   Figure 1c.  Aortic dissection in a patient who presented with severe chest, abdominal, and lower extremity pain with no palpable femoral pulses. The patient had recently undergone aortic valve replacement and coronary artery bypass surgery. (a) CT scan shows a type A dissection extending to the aortic bifurcation. There is narrowing of the true lumen of the aorta at the level of the renal arteries, with the left renal artery (arrow) arising from the false lumen (F). (b) CT scan obtained inferior to a shows the true lumen of the aorta compressed to a slit (arrow) by the nonenhanced but hypertensive false lumen (F). A horseshoe kidney is also seen (*). It was felt that the risk posed by further aortic surgery was too high, and fenestration was requested to restore lower extremity circulation. (c) Pelvic arteriogram obtained with access from the right femoral artery shows significant obstruction at the lower aorta, as predicted from the CT scans (cf a, b). (d) Aortogram shows two right renal arteries arising from the true lumen, with severe narrowing of the infrarenal aorta (arrows). (e) Intravascular ultrasonographic (US) image helps confirm that access was into the true lumen and that there was adequate space to puncture the center of the flap (arrows), with over 1 cm of false lumen depth (*) beyond the flap. (f) Digital image shows a Rösch-Uchida needle (Cook, Bloomington, Ind) (arrow) that was inserted to the level of the intravascular US transducer (arrowhead). Intravascular US was used to guide the puncture. (g) Intravascular US image shows the needle tip (arrow) in the middle of the flap. (h) Intravascular US image demonstrates a balloon (arrows) that has been dilated to 18 mm and is correctly positioned; as a result, the pressures in the true and false lumina were equalized. (i) Aortogram shows filling of the left renal artery from the false lumen (arrow), with persistent narrowing of the lower aorta in spite of balloon angioplasty. (j) Aortogram shows coaxial deployment of two of the largest stents available at that time (20 x 40 Wallstents; Boston Scientific, Natick, Mass) within the true lumen (arrowheads) and below the upper left renal artery origin (arrow). The procedure was successful in preventing recoil of the obstruction, and there was no significant pressure gradient. Following this procedure, the patient’s lower extremity rest pain resolved and his femoral and distal pulses returned (there was no infrainguinal obstructive disease).

View larger version (121K): [in a new window]   Figure 1d.  Aortic dissection in a patient who presented with severe chest, abdominal, and lower extremity pain with no palpable femoral pulses. The patient had recently undergone aortic valve replacement and coronary artery bypass surgery. (a) CT scan shows a type A dissection extending to the aortic bifurcation. There is narrowing of the true lumen of the aorta at the level of the renal arteries, with the left renal artery (arrow) arising from the false lumen (F). (b) CT scan obtained inferior to a shows the true lumen of the aorta compressed to a slit (arrow) by the nonenhanced but hypertensive false lumen (F). A horseshoe kidney is also seen (*). It was felt that the risk posed by further aortic surgery was too high, and fenestration was requested to restore lower extremity circulation. (c) Pelvic arteriogram obtained with access from the right femoral artery shows significant obstruction at the lower aorta, as predicted from the CT scans (cf a, b). (d) Aortogram shows two right renal arteries arising from the true lumen, with severe narrowing of the infrarenal aorta (arrows). (e) Intravascular ultrasonographic (US) image helps confirm that access was into the true lumen and that there was adequate space to puncture the center of the flap (arrows), with over 1 cm of false lumen depth (*) beyond the flap. (f) Digital image shows a Rösch-Uchida needle (Cook, Bloomington, Ind) (arrow) that was inserted to the level of the intravascular US transducer (arrowhead). Intravascular US was used to guide the puncture. (g) Intravascular US image shows the needle tip (arrow) in the middle of the flap. (h) Intravascular US image demonstrates a balloon (arrows) that has been dilated to 18 mm and is correctly positioned; as a result, the pressures in the true and false lumina were equalized. (i) Aortogram shows filling of the left renal artery from the false lumen (arrow), with persistent narrowing of the lower aorta in spite of balloon angioplasty. (j) Aortogram shows coaxial deployment of two of the largest stents available at that time (20 x 40 Wallstents; Boston Scientific, Natick, Mass) within the true lumen (arrowheads) and below the upper left renal artery origin (arrow). The procedure was successful in preventing recoil of the obstruction, and there was no significant pressure gradient. Following this procedure, the patient’s lower extremity rest pain resolved and his femoral and distal pulses returned (there was no infrainguinal obstructive disease).

View larger version (168K): [in a new window]   Figure 1e.  Aortic dissection in a patient who presented with severe chest, abdominal, and lower extremity pain with no palpable femoral pulses. The patient had recently undergone aortic valve replacement and coronary artery bypass surgery. (a) CT scan shows a type A dissection extending to the aortic bifurcation. There is narrowing of the true lumen of the aorta at the level of the renal arteries, with the left renal artery (arrow) arising from the false lumen (F). (b) CT scan obtained inferior to a shows the true lumen of the aorta compressed to a slit (arrow) by the nonenhanced but hypertensive false lumen (F). A horseshoe kidney is also seen (*). It was felt that the risk posed by further aortic surgery was too high, and fenestration was requested to restore lower extremity circulation. (c) Pelvic arteriogram obtained with access from the right femoral artery shows significant obstruction at the lower aorta, as predicted from the CT scans (cf a, b). (d) Aortogram shows two right renal arteries arising from the true lumen, with severe narrowing of the infrarenal aorta (arrows). (e) Intravascular ultrasonographic (US) image helps confirm that access was into the true lumen and that there was adequate space to puncture the center of the flap (arrows), with over 1 cm of false lumen depth (*) beyond the flap. (f) Digital image shows a Rösch-Uchida needle (Cook, Bloomington, Ind) (arrow) that was inserted to the level of the intravascular US transducer (arrowhead). Intravascular US was used to guide the puncture. (g) Intravascular US image shows the needle tip (arrow) in the middle of the flap. (h) Intravascular US image demonstrates a balloon (arrows) that has been dilated to 18 mm and is correctly positioned; as a result, the pressures in the true and false lumina were equalized. (i) Aortogram shows filling of the left renal artery from the false lumen (arrow), with persistent narrowing of the lower aorta in spite of balloon angioplasty. (j) Aortogram shows coaxial deployment of two of the largest stents available at that time (20 x 40 Wallstents; Boston Scientific, Natick, Mass) within the true lumen (arrowheads) and below the upper left renal artery origin (arrow). The procedure was successful in preventing recoil of the obstruction, and there was no significant pressure gradient. Following this procedure, the patient’s lower extremity rest pain resolved and his femoral and distal pulses returned (there was no infrainguinal obstructive disease).

View larger version (126K): [in a new window]   Figure 1f.  Aortic dissection in a patient who presented with severe chest, abdominal, and lower extremity pain with no palpable femoral pulses. The patient had recently undergone aortic valve replacement and coronary artery bypass surgery. (a) CT scan shows a type A dissection extending to the aortic bifurcation. There is narrowing of the true lumen of the aorta at the level of the renal arteries, with the left renal artery (arrow) arising from the false lumen (F). (b) CT scan obtained inferior to a shows the true lumen of the aorta compressed to a slit (arrow) by the nonenhanced but hypertensive false lumen (F). A horseshoe kidney is also seen (*). It was felt that the risk posed by further aortic surgery was too high, and fenestration was requested to restore lower extremity circulation. (c) Pelvic arteriogram obtained with access from the right femoral artery shows significant obstruction at the lower aorta, as predicted from the CT scans (cf a, b). (d) Aortogram shows two right renal arteries arising from the true lumen, with severe narrowing of the infrarenal aorta (arrows). (e) Intravascular ultrasonographic (US) image helps confirm that access was into the true lumen and that there was adequate space to puncture the center of the flap (arrows), with over 1 cm of false lumen depth (*) beyond the flap. (f) Digital image shows a Rösch-Uchida needle (Cook, Bloomington, Ind) (arrow) that was inserted to the level of the intravascular US transducer (arrowhead). Intravascular US was used to guide the puncture. (g) Intravascular US image shows the needle tip (arrow) in the middle of the flap. (h) Intravascular US image demonstrates a balloon (arrows) that has been dilated to 18 mm and is correctly positioned; as a result, the pressures in the true and false lumina were equalized. (i) Aortogram shows filling of the left renal artery from the false lumen (arrow), with persistent narrowing of the lower aorta in spite of balloon angioplasty. (j) Aortogram shows coaxial deployment of two of the largest stents available at that time (20 x 40 Wallstents; Boston Scientific, Natick, Mass) within the true lumen (arrowheads) and below the upper left renal artery origin (arrow). The procedure was successful in preventing recoil of the obstruction, and there was no significant pressure gradient. Following this procedure, the patient’s lower extremity rest pain resolved and his femoral and distal pulses returned (there was no infrainguinal obstructive disease).

View larger version (156K): [in a new window]   Figure 1g.  Aortic dissection in a patient who presented with severe chest, abdominal, and lower extremity pain with no palpable femoral pulses. The patient had recently undergone aortic valve replacement and coronary artery bypass surgery. (a) CT scan shows a type A dissection extending to the aortic bifurcation. There is narrowing of the true lumen of the aorta at the level of the renal arteries, with the left renal artery (arrow) arising from the false lumen (F). (b) CT scan obtained inferior to a shows the true lumen of the aorta compressed to a slit (arrow) by the nonenhanced but hypertensive false lumen (F). A horseshoe kidney is also seen (*). It was felt that the risk posed by further aortic surgery was too high, and fenestration was requested to restore lower extremity circulation. (c) Pelvic arteriogram obtained with access from the right femoral artery shows significant obstruction at the lower aorta, as predicted from the CT scans (cf a, b). (d) Aortogram shows two right renal arteries arising from the true lumen, with severe narrowing of the infrarenal aorta (arrows). (e) Intravascular ultrasonographic (US) image helps confirm that access was into the true lumen and that there was adequate space to puncture the center of the flap (arrows), with over 1 cm of false lumen depth (*) beyond the flap. (f) Digital image shows a Rösch-Uchida needle (Cook, Bloomington, Ind) (arrow) that was inserted to the level of the intravascular US transducer (arrowhead). Intravascular US was used to guide the puncture. (g) Intravascular US image shows the needle tip (arrow) in the middle of the flap. (h) Intravascular US image demonstrates a balloon (arrows) that has been dilated to 18 mm and is correctly positioned; as a result, the pressures in the true and false lumina were equalized. (i) Aortogram shows filling of the left renal artery from the false lumen (arrow), with persistent narrowing of the lower aorta in spite of balloon angioplasty. (j) Aortogram shows coaxial deployment of two of the largest stents available at that time (20 x 40 Wallstents; Boston Scientific, Natick, Mass) within the true lumen (arrowheads) and below the upper left renal artery origin (arrow). The procedure was successful in preventing recoil of the obstruction, and there was no significant pressure gradient. Following this procedure, the patient’s lower extremity rest pain resolved and his femoral and distal pulses returned (there was no infrainguinal obstructive disease).

View larger version (165K): [in a new window]   Figure 1h.  Aortic dissection in a patient who presented with severe chest, abdominal, and lower extremity pain with no palpable femoral pulses. The patient had recently undergone aortic valve replacement and coronary artery bypass surgery. (a) CT scan shows a type A dissection extending to the aortic bifurcation. There is narrowing of the true lumen of the aorta at the level of the renal arteries, with the left renal artery (arrow) arising from the false lumen (F). (b) CT scan obtained inferior to a shows the true lumen of the aorta compressed to a slit (arrow) by the nonenhanced but hypertensive false lumen (F). A horseshoe kidney is also seen (*). It was felt that the risk posed by further aortic surgery was too high, and fenestration was requested to restore lower extremity circulation. (c) Pelvic arteriogram obtained with access from the right femoral artery shows significant obstruction at the lower aorta, as predicted from the CT scans (cf a, b). (d) Aortogram shows two right renal arteries arising from the true lumen, with severe narrowing of the infrarenal aorta (arrows). (e) Intravascular ultrasonographic (US) image helps confirm that access was into the true lumen and that there was adequate space to puncture the center of the flap (arrows), with over 1 cm of false lumen depth (*) beyond the flap. (f) Digital image shows a Rösch-Uchida needle (Cook, Bloomington, Ind) (arrow) that was inserted to the level of the intravascular US transducer (arrowhead). Intravascular US was used to guide the puncture. (g) Intravascular US image shows the needle tip (arrow) in the middle of the flap. (h) Intravascular US image demonstrates a balloon (arrows) that has been dilated to 18 mm and is correctly positioned; as a result, the pressures in the true and false lumina were equalized. (i) Aortogram shows filling of the left renal artery from the false lumen (arrow), with persistent narrowing of the lower aorta in spite of balloon angioplasty. (j) Aortogram shows coaxial deployment of two of the largest stents available at that time (20 x 40 Wallstents; Boston Scientific, Natick, Mass) within the true lumen (arrowheads) and below the upper left renal artery origin (arrow). The procedure was successful in preventing recoil of the obstruction, and there was no significant pressure gradient. Following this procedure, the patient’s lower extremity rest pain resolved and his femoral and distal pulses returned (there was no infrainguinal obstructive disease).

View larger version (122K): [in a new window]   Figure 1i.  Aortic dissection in a patient who presented with severe chest, abdominal, and lower extremity pain with no palpable femoral pulses. The patient had recently undergone aortic valve replacement and coronary artery bypass surgery. (a) CT scan shows a type A dissection extending to the aortic bifurcation. There is narrowing of the true lumen of the aorta at the level of the renal arteries, with the left renal artery (arrow) arising from the false lumen (F). (b) CT scan obtained inferior to a shows the true lumen of the aorta compressed to a slit (arrow) by the nonenhanced but hypertensive false lumen (F). A horseshoe kidney is also seen (*). It was felt that the risk posed by further aortic surgery was too high, and fenestration was requested to restore lower extremity circulation. (c) Pelvic arteriogram obtained with access from the right femoral artery shows significant obstruction at the lower aorta, as predicted from the CT scans (cf a, b). (d) Aortogram shows two right renal arteries arising from the true lumen, with severe narrowing of the infrarenal aorta (arrows). (e) Intravascular ultrasonographic (US) image helps confirm that access was into the true lumen and that there was adequate space to puncture the center of the flap (arrows), with over 1 cm of false lumen depth (*) beyond the flap. (f) Digital image shows a Rösch-Uchida needle (Cook, Bloomington, Ind) (arrow) that was inserted to the level of the intravascular US transducer (arrowhead). Intravascular US was used to guide the puncture. (g) Intravascular US image shows the needle tip (arrow) in the middle of the flap. (h) Intravascular US image demonstrates a balloon (arrows) that has been dilated to 18 mm and is correctly positioned; as a result, the pressures in the true and false lumina were equalized. (i) Aortogram shows filling of the left renal artery from the false lumen (arrow), with persistent narrowing of the lower aorta in spite of balloon angioplasty. (j) Aortogram shows coaxial deployment of two of the largest stents available at that time (20 x 40 Wallstents; Boston Scientific, Natick, Mass) within the true lumen (arrowheads) and below the upper left renal artery origin (arrow). The procedure was successful in preventing recoil of the obstruction, and there was no significant pressure gradient. Following this procedure, the patient’s lower extremity rest pain resolved and his femoral and distal pulses returned (there was no infrainguinal obstructive disease).

View larger version (119K): [in a new window]   Figure 1j.  Aortic dissection in a patient who presented with severe chest, abdominal, and lower extremity pain with no palpable femoral pulses. The patient had recently undergone aortic valve replacement and coronary artery bypass surgery. (a) CT scan shows a type A dissection extending to the aortic bifurcation. There is narrowing of the true lumen of the aorta at the level of the renal arteries, with the left renal artery (arrow) arising from the false lumen (F). (b) CT scan obtained inferior to a shows the true lumen of the aorta compressed to a slit (arrow) by the nonenhanced but hypertensive false lumen (F). A horseshoe kidney is also seen (*). It was felt that the risk posed by further aortic surgery was too high, and fenestration was requested to restore lower extremity circulation. (c) Pelvic arteriogram obtained with access from the right femoral artery shows significant obstruction at the lower aorta, as predicted from the CT scans (cf a, b). (d) Aortogram shows two right renal arteries arising from the true lumen, with severe narrowing of the infrarenal aorta (arrows). (e) Intravascular ultrasonographic (US) image helps confirm that access was into the true lumen and that there was adequate space to puncture the center of the flap (arrows), with over 1 cm of false lumen depth (*) beyond the flap. (f) Digital image shows a Rösch-Uchida needle (Cook, Bloomington, Ind) (arrow) that was inserted to the level of the intravascular US transducer (arrowhead). Intravascular US was used to guide the puncture. (g) Intravascular US image shows the needle tip (arrow) in the middle of the flap. (h) Intravascular US image demonstrates a balloon (arrows) that has been dilated to 18 mm and is correctly positioned; as a result, the pressures in the true and false lumina were equalized. (i) Aortogram shows filling of the left renal artery from the false lumen (arrow), with persistent narrowing of the lower aorta in spite of balloon angioplasty. (j) Aortogram shows coaxial deployment of two of the largest stents available at that time (20 x 40 Wallstents; Boston Scientific, Natick, Mass) within the true lumen (arrowheads) and below the upper left renal artery origin (arrow). The procedure was successful in preventing recoil of the obstruction, and there was no significant pressure gradient. Following this procedure, the patient’s lower extremity rest pain resolved and his femoral and distal pulses returned (there was no infrainguinal obstructive disease).

View larger version (162K): [in a new window]   Figure 2a.  Branch vessel involvement in a patient with type B dissection who presented with right leg pain and hypertension. Fenestration and stent placement were performed to restore renal and right leg blood flow. (a) Aortogram obtained with the catheter in the true lumen shows severe compression of the true lumen (arrows) by the false lumen. The left renal artery arises from the true lumen, and the mesenteric arteries arise at the junction of the flap and the true lumen. The catheter was repositioned, and contrast material was injected into the false lumen. (b) Aortogram shows opacification of the renal arteries and inferior mesenteric artery. There is severe narrowing of the origin of the right common iliac artery (arrow). (c) Digital image shows a balloon passing through a small, spontaneous inferior tear that was dilated to 16 mm and a superior tear at the renal artery level that was dilated to 20 mm. (d) Aortogram demonstrates severe narrowing of the infrarenal aorta (arrow), which persisted despite the fact that at this stage the pressure in the false lumen was the same as that in the true lumen. Two 20 x 40 Wallstents were placed immediately below the renal artery origins. (e) Aortogram reveals that good flow has been restored to the renal arteries (arrows) but that the iliac artery stenosis persists. Two 10 x 40 Wallstents were inserted. (f) Aortogram shows relief of the iliac artery obstruction (arrows). The patient remained well with no evidence of distal, renal, or mesenteric ischemia. After 15 months, she required repair of the thoracic aorta due to asymptomatic enlargement of the aorta at the site of the proximal tear. (g) CT angiogram obtained 1 month after repair of the thoracic aorta shows widely patent aortic and iliac artery stents (arrows). There has been no subsequent need for infradiaphragmatic intervention.

View larger version (173K): [in a new window]   Figure 2b.  Branch vessel involvement in a patient with type B dissection who presented with right leg pain and hypertension. Fenestration and stent placement were performed to restore renal and right leg blood flow. (a) Aortogram obtained with the catheter in the true lumen shows severe compression of the true lumen (arrows) by the false lumen. The left renal artery arises from the true lumen, and the mesenteric arteries arise at the junction of the flap and the true lumen. The catheter was repositioned, and contrast material was injected into the false lumen. (b) Aortogram shows opacification of the renal arteries and inferior mesenteric artery. There is severe narrowing of the origin of the right common iliac artery (arrow). (c) Digital image shows a balloon passing through a small, spontaneous inferior tear that was dilated to 16 mm and a superior tear at the renal artery level that was dilated to 20 mm. (d) Aortogram demonstrates severe narrowing of the infrarenal aorta (arrow), which persisted despite the fact that at this stage the pressure in the false lumen was the same as that in the true lumen. Two 20 x 40 Wallstents were placed immediately below the renal artery origins. (e) Aortogram reveals that good flow has been restored to the renal arteries (arrows) but that the iliac artery stenosis persists. Two 10 x 40 Wallstents were inserted. (f) Aortogram shows relief of the iliac artery obstruction (arrows). The patient remained well with no evidence of distal, renal, or mesenteric ischemia. After 15 months, she required repair of the thoracic aorta due to asymptomatic enlargement of the aorta at the site of the proximal tear. (g) CT angiogram obtained 1 month after repair of the thoracic aorta shows widely patent aortic and iliac artery stents (arrows). There has been no subsequent need for infradiaphragmatic intervention.

View larger version (133K): [in a new window]   Figure 2c.  Branch vessel involvement in a patient with type B dissection who presented with right leg pain and hypertension. Fenestration and stent placement were performed to restore renal and right leg blood flow. (a) Aortogram obtained with the catheter in the true lumen shows severe compression of the true lumen (arrows) by the false lumen. The left renal artery arises from the true lumen, and the mesenteric arteries arise at the junction of the flap and the true lumen. The catheter was repositioned, and contrast material was injected into the false lumen. (b) Aortogram shows opacification of the renal arteries and inferior mesenteric artery. There is severe narrowing of the origin of the right common iliac artery (arrow). (c) Digital image shows a balloon passing through a small, spontaneous inferior tear that was dilated to 16 mm and a superior tear at the renal artery level that was dilated to 20 mm. (d) Aortogram demonstrates severe narrowing of the infrarenal aorta (arrow), which persisted despite the fact that at this stage the pressure in the false lumen was the same as that in the true lumen. Two 20 x 40 Wallstents were placed immediately below the renal artery origins. (e) Aortogram reveals that good flow has been restored to the renal arteries (arrows) but that the iliac artery stenosis persists. Two 10 x 40 Wallstents were inserted. (f) Aortogram shows relief of the iliac artery obstruction (arrows). The patient remained well with no evidence of distal, renal, or mesenteric ischemia. After 15 months, she required repair of the thoracic aorta due to asymptomatic enlargement of the aorta at the site of the proximal tear. (g) CT angiogram obtained 1 month after repair of the thoracic aorta shows widely patent aortic and iliac artery stents (arrows). There has been no subsequent need for infradiaphragmatic intervention.

View larger version (126K): [in a new window]   Figure 2d.  Branch vessel involvement in a patient with type B dissection who presented with right leg pain and hypertension. Fenestration and stent placement were performed to restore renal and right leg blood flow. (a) Aortogram obtained with the catheter in the true lumen shows severe compression of the true lumen (arrows) by the false lumen. The left renal artery arises from the true lumen, and the mesenteric arteries arise at the junction of the flap and the true lumen. The catheter was repositioned, and contrast material was injected into the false lumen. (b) Aortogram shows opacification of the renal arteries and inferior mesenteric artery. There is severe narrowing of the origin of the right common iliac artery (arrow). (c) Digital image shows a balloon passing through a small, spontaneous inferior tear that was dilated to 16 mm and a superior tear at the renal artery level that was dilated to 20 mm. (d) Aortogram demonstrates severe narrowing of the infrarenal aorta (arrow), which persisted despite the fact that at this stage the pressure in the false lumen was the same as that in the true lumen. Two 20 x 40 Wallstents were placed immediately below the renal artery origins. (e) Aortogram reveals that good flow has been restored to the renal arteries (arrows) but that the iliac artery stenosis persists. Two 10 x 40 Wallstents were inserted. (f) Aortogram shows relief of the iliac artery obstruction (arrows). The patient remained well with no evidence of distal, renal, or mesenteric ischemia. After 15 months, she required repair of the thoracic aorta due to asymptomatic enlargement of the aorta at the site of the proximal tear. (g) CT angiogram obtained 1 month after repair of the thoracic aorta shows widely patent aortic and iliac artery stents (arrows). There has been no subsequent need for infradiaphragmatic intervention.

View larger version (167K): [in a new window]   Figure 2e.  Branch vessel involvement in a patient with type B dissection who presented with right leg pain and hypertension. Fenestration and stent placement were performed to restore renal and right leg blood flow. (a) Aortogram obtained with the catheter in the true lumen shows severe compression of the true lumen (arrows) by the false lumen. The left renal artery arises from the true lumen, and the mesenteric arteries arise at the junction of the flap and the true lumen. The catheter was repositioned, and contrast material was injected into the false lumen. (b) Aortogram shows opacification of the renal arteries and inferior mesenteric artery. There is severe narrowing of the origin of the right common iliac artery (arrow). (c) Digital image shows a balloon passing through a small, spontaneous inferior tear that was dilated to 16 mm and a superior tear at the renal artery level that was dilated to 20 mm. (d) Aortogram demonstrates severe narrowing of the infrarenal aorta (arrow), which persisted despite the fact that at this stage the pressure in the false lumen was the same as that in the true lumen. Two 20 x 40 Wallstents were placed immediately below the renal artery origins. (e) Aortogram reveals that good flow has been restored to the renal arteries (arrows) but that the iliac artery stenosis persists. Two 10 x 40 Wallstents were inserted. (f) Aortogram shows relief of the iliac artery obstruction (arrows). The patient remained well with no evidence of distal, renal, or mesenteric ischemia. After 15 months, she required repair of the thoracic aorta due to asymptomatic enlargement of the aorta at the site of the proximal tear. (g) CT angiogram obtained 1 month after repair of the thoracic aorta shows widely patent aortic and iliac artery stents (arrows). There has been no subsequent need for infradiaphragmatic intervention.

View larger version (146K): [in a new window]   Figure 2f.  Branch vessel involvement in a patient with type B dissection who presented with right leg pain and hypertension. Fenestration and stent placement were performed to restore renal and right leg blood flow. (a) Aortogram obtained with the catheter in the true lumen shows severe compression of the true lumen (arrows) by the false lumen. The left renal artery arises from the true lumen, and the mesenteric arteries arise at the junction of the flap and the true lumen. The catheter was repositioned, and contrast material was injected into the false lumen. (b) Aortogram shows opacification of the renal arteries and inferior mesenteric artery. There is severe narrowing of the origin of the right common iliac artery (arrow). (c) Digital image shows a balloon passing through a small, spontaneous inferior tear that was dilated to 16 mm and a superior tear at the renal artery level that was dilated to 20 mm. (d) Aortogram demonstrates severe narrowing of the infrarenal aorta (arrow), which persisted despite the fact that at this stage the pressure in the false lumen was the same as that in the true lumen. Two 20 x 40 Wallstents were placed immediately below the renal artery origins. (e) Aortogram reveals that good flow has been restored to the renal arteries (arrows) but that the iliac artery stenosis persists. Two 10 x 40 Wallstents were inserted. (f) Aortogram shows relief of the iliac artery obstruction (arrows). The patient remained well with no evidence of distal, renal, or mesenteric ischemia. After 15 months, she required repair of the thoracic aorta due to asymptomatic enlargement of the aorta at the site of the proximal tear. (g) CT angiogram obtained 1 month after repair of the thoracic aorta shows widely patent aortic and iliac artery stents (arrows). There has been no subsequent need for infradiaphragmatic intervention.

View larger version (126K): [in a new window]   Figure 2g.  Branch vessel involvement in a patient with type B dissection who presented with right leg pain and hypertension. Fenestration and stent placement were performed to restore renal and right leg blood flow. (a) Aortogram obtained with the catheter in the true lumen shows severe compression of the true lumen (arrows) by the false lumen. The left renal artery arises from the true lumen, and the mesenteric arteries arise at the junction of the flap and the true lumen. The catheter was repositioned, and contrast material was injected into the false lumen. (b) Aortogram shows opacification of the renal arteries and inferior mesenteric artery. There is severe narrowing of the origin of the right common iliac artery (arrow). (c) Digital image shows a balloon passing through a small, spontaneous inferior tear that was dilated to 16 mm and a superior tear at the renal artery level that was dilated to 20 mm. (d) Aortogram demonstrates severe narrowing of the infrarenal aorta (arrow), which persisted despite the fact that at this stage the pressure in the false lumen was the same as that in the true lumen. Two 20 x 40 Wallstents were placed immediately below the renal artery origins. (e) Aortogram reveals that good flow has been restored to the renal arteries (arrows) but that the iliac artery stenosis persists. Two 10 x 40 Wallstents were inserted. (f) Aortogram shows relief of the iliac artery obstruction (arrows). The patient remained well with no evidence of distal, renal, or mesenteric ischemia. After 15 months, she required repair of the thoracic aorta due to asymptomatic enlargement of the aorta at the site of the proximal tear. (g) CT angiogram obtained 1 month after repair of the thoracic aorta shows widely patent aortic and iliac artery stents (arrows). There has been no subsequent need for infradiaphragmatic intervention.

View larger version (189K): [in a new window]   Figure 3a.  Branch vessel involvement in a patient with type B dissection who presented with severe abdominal and leg pain and severe hypertension. (a) Aortogram shows severe compression of the true lumen, with poor filling of the upper right renal artery (arrow) and reduced filling of the superior mesenteric artery (SMA). (b) Aortogram obtained at the level of the right lower pole renal artery (arrow) shows near obliteration of the true lumen by the false lumen. Arterial pressure was unmeasurable at the level of the aortic bifurcation. (c) Lateral aortogram shows narrowing of the true lumen (arrows) by the posterior false lumen, with the flap nearly occluding the origins of the celiac artery and SMA (arrowheads). (d) Digital image shows an Amplatz snare in the false lumen that was used as a target for flap puncture. The intravascular US transducer (IVUS) prevented proper positioning of the puncture needle, leading to puncture outside the aorta as indicated by the extravasated contrast material (black arrow). (e) Digital image demonstrates inflation of the dilatation balloon inside the snare, which has been pulled back over the wire to the site of the puncture through the dissection flap. This helps confirm correct positioning for fenestration. Stents were placed in the infrarenal aorta (coaxial Wallstents) and iliac arteries (Smartstent; Cordis, Miami, Fla). (f) Aortogram shows much better flow to the legs and renal arteries, including the left lower pole renal artery (arrow). Pressure was 114/65 mm Hg in the aorta, 115/65 mm Hg in the true lumen of the left external iliac artery, and 112/62 mm Hg in the false lumen at the same level. (g) Lateral aortogram shows that, in spite of the use of large coaxial stents, the false lumen still distorts the true lumen, although this did not cause a pressure gradient. (h) CT scan obtained over 3 months later shows continuing compression of the stent by the false lumen. However, the patient remains asymptomatic over 11 months after fenestration and no further intervention is currently planned.

View larger version (129K): [in a new window]   Figure 3b.  Branch vessel involvement in a patient with type B dissection who presented with severe abdominal and leg pain and severe hypertension. (a) Aortogram shows severe compression of the true lumen, with poor filling of the upper right renal artery (arrow) and reduced filling of the superior mesenteric artery (SMA). (b) Aortogram obtained at the level of the right lower pole renal artery (arrow) shows near obliteration of the true lumen by the false lumen. Arterial pressure was unmeasurable at the level of the aortic bifurcation. (c) Lateral aortogram shows narrowing of the true lumen (arrows) by the posterior false lumen, with the flap nearly occluding the origins of the celiac artery and SMA (arrowheads). (d) Digital image shows an Amplatz snare in the false lumen that was used as a target for flap puncture. The intravascular US transducer (IVUS) prevented proper positioning of the puncture needle, leading to puncture outside the aorta as indicated by the extravasated contrast material (black arrow). (e) Digital image demonstrates inflation of the dilatation balloon inside the snare, which has been pulled back over the wire to the site of the puncture through the dissection flap. This helps confirm correct positioning for fenestration. Stents were placed in the infrarenal aorta (coaxial Wallstents) and iliac arteries (Smartstent; Cordis, Miami, Fla). (f) Aortogram shows much better flow to the legs and renal arteries, including the left lower pole renal artery (arrow). Pressure was 114/65 mm Hg in the aorta, 115/65 mm Hg in the true lumen of the left external iliac artery, and 112/62 mm Hg in the false lumen at the same level. (g) Lateral aortogram shows that, in spite of the use of large coaxial stents, the false lumen still distorts the true lumen, although this did not cause a pressure gradient. (h) CT scan obtained over 3 months later shows continuing compression of the stent by the false lumen. However, the patient remains asymptomatic over 11 months after fenestration and no further intervention is currently planned.

View larger version (146K): [in a new window]   Figure 3c.  Branch vessel involvement in a patient with type B dissection who presented with severe abdominal and leg pain and severe hypertension. (a) Aortogram shows severe compression of the true lumen, with poor filling of the upper right renal artery (arrow) and reduced filling of the superior mesenteric artery (SMA). (b) Aortogram obtained at the level of the right lower pole renal artery (arrow) shows near obliteration of the true lumen by the false lumen. Arterial pressure was unmeasurable at the level of the aortic bifurcation. (c) Lateral aortogram shows narrowing of the true lumen (arrows) by the posterior false lumen, with the flap nearly occluding the origins of the celiac artery and SMA (arrowheads). (d) Digital image shows an Amplatz snare in the false lumen that was used as a target for flap puncture. The intravascular US transducer (IVUS) prevented proper positioning of the puncture needle, leading to puncture outside the aorta as indicated by the extravasated contrast material (black arrow). (e) Digital image demonstrates inflation of the dilatation balloon inside the snare, which has been pulled back over the wire to the site of the puncture through the dissection flap. This helps confirm correct positioning for fenestration. Stents were placed in the infrarenal aorta (coaxial Wallstents) and iliac arteries (Smartstent; Cordis, Miami, Fla). (f) Aortogram shows much better flow to the legs and renal arteries, including the left lower pole renal artery (arrow). Pressure was 114/65 mm Hg in the aorta, 115/65 mm Hg in the true lumen of the left external iliac artery, and 112/62 mm Hg in the false lumen at the same level. (g) Lateral aortogram shows that, in spite of the use of large coaxial stents, the false lumen still distorts the true lumen, although this did not cause a pressure gradient. (h) CT scan obtained over 3 months later shows continuing compression of the stent by the false lumen. However, the patient remains asymptomatic over 11 months after fenestration and no further intervention is currently planned.

View larger version (127K): [in a new window]   Figure 3d.  Branch vessel involvement in a patient with type B dissection who presented with severe abdominal and leg pain and severe hypertension. (a) Aortogram shows severe compression of the true lumen, with poor filling of the upper right renal artery (arrow) and reduced filling of the superior mesenteric artery (SMA). (b) Aortogram obtained at the level of the right lower pole renal artery (arrow) shows near obliteration of the true lumen by the false lumen. Arterial pressure was unmeasurable at the level of the aortic bifurcation. (c) Lateral aortogram shows narrowing of the true lumen (arrows) by the posterior false lumen, with the flap nearly occluding the origins of the celiac artery and SMA (arrowheads). (d) Digital image shows an Amplatz snare in the false lumen that was used as a target for flap puncture. The intravascular US transducer (IVUS) prevented proper positioning of the puncture needle, leading to puncture outside the aorta as indicated by the extravasated contrast material (black arrow). (e) Digital image demonstrates inflation of the dilatation balloon inside the snare, which has been pulled back over the wire to the site of the puncture through the dissection flap. This helps confirm correct positioning for fenestration. Stents were placed in the infrarenal aorta (coaxial Wallstents) and iliac arteries (Smartstent; Cordis, Miami, Fla). (f) Aortogram shows much better flow to the legs and renal arteries, including the left lower pole renal artery (arrow). Pressure was 114/65 mm Hg in the aorta, 115/65 mm Hg in the true lumen of the left external iliac artery, and 112/62 mm Hg in the false lumen at the same level. (g) Lateral aortogram shows that, in spite of the use of large coaxial stents, the false lumen still distorts the true lumen, although this did not cause a pressure gradient. (h) CT scan obtained over 3 months later shows continuing compression of the stent by the false lumen. However, the patient remains asymptomatic over 11 months after fenestration and no further intervention is currently planned.

View larger version (155K): [in a new window]   Figure 3e.  Branch vessel involvement in a patient with type B dissection who presented with severe abdominal and leg pain and severe hypertension. (a) Aortogram shows severe compression of the true lumen, with poor filling of the upper right renal artery (arrow) and reduced filling of the superior mesenteric artery (SMA). (b) Aortogram obtained at the level of the right lower pole renal artery (arrow) shows near obliteration of the true lumen by the false lumen. Arterial pressure was unmeasurable at the level of the aortic bifurcation. (c) Lateral aortogram shows narrowing of the true lumen (arrows) by the posterior false lumen, with the flap nearly occluding the origins of the celiac artery and SMA (arrowheads). (d) Digital image shows an Amplatz snare in the false lumen that was used as a target for flap puncture. The intravascular US transducer (IVUS) prevented proper positioning of the puncture needle, leading to puncture outside the aorta as indicated by the extravasated contrast material (black arrow). (e) Digital image demonstrates inflation of the dilatation balloon inside the snare, which has been pulled back over the wire to the site of the puncture through the dissection flap. This helps confirm correct positioning for fenestration. Stents were placed in the infrarenal aorta (coaxial Wallstents) and iliac arteries (Smartstent; Cordis, Miami, Fla). (f) Aortogram shows much better flow to the legs and renal arteries, including the left lower pole renal artery (arrow). Pressure was 114/65 mm Hg in the aorta, 115/65 mm Hg in the true lumen of the left external iliac artery, and 112/62 mm Hg in the false lumen at the same level. (g) Lateral aortogram shows that, in spite of the use of large coaxial stents, the false lumen still distorts the true lumen, although this did not cause a pressure gradient. (h) CT scan obtained over 3 months later shows continuing compression of the stent by the false lumen. However, the patient remains asymptomatic over 11 months after fenestration and no further intervention is currently planned.

View larger version (189K): [in a new window]   Figure 3f.  Branch vessel involvement in a patient with type B dissection who presented with severe abdominal and leg pain and severe hypertension. (a) Aortogram shows severe compression of the true lumen, with poor filling of the upper right renal artery (arrow) and reduced filling of the superior mesenteric artery (SMA). (b) Aortogram obtained at the level of the right lower pole renal artery (arrow) shows near obliteration of the true lumen by the false lumen. Arterial pressure was unmeasurable at the level of the aortic bifurcation. (c) Lateral aortogram shows narrowing of the true lumen (arrows) by the posterior false lumen, with the flap nearly occluding the origins of the celiac artery and SMA (arrowheads). (d) Digital image shows an Amplatz snare in the false lumen that was used as a target for flap puncture. The intravascular US transducer (IVUS) prevented proper positioning of the puncture needle, leading to puncture outside the aorta as indicated by the extravasated contrast material (black arrow). (e) Digital image demonstrates inflation of the dilatation balloon inside the snare, which has been pulled back over the wire to the site of the puncture through the dissection flap. This helps confirm correct positioning for fenestration. Stents were placed in the infrarenal aorta (coaxial Wallstents) and iliac arteries (Smartstent; Cordis, Miami, Fla). (f) Aortogram shows much better flow to the legs and renal arteries, including the left lower pole renal artery (arrow). Pressure was 114/65 mm Hg in the aorta, 115/65 mm Hg in the true lumen of the left external iliac artery, and 112/62 mm Hg in the false lumen at the same level. (g) Lateral aortogram shows that, in spite of the use of large coaxial stents, the false lumen still distorts the true lumen, although this did not cause a pressure gradient. (h) CT scan obtained over 3 months later shows continuing compression of the stent by the false lumen. However, the patient remains asymptomatic over 11 months after fenestration and no further intervention is currently planned.

View larger version (124K): [in a new window]   Figure 3g.  Branch vessel involvement in a patient with type B dissection who presented with severe abdominal and leg pain and severe hypertension. (a) Aortogram shows severe compression of the true lumen, with poor filling of the upper right renal artery (arrow) and reduced filling of the superior mesenteric artery (SMA). (b) Aortogram obtained at the level of the right lower pole renal artery (arrow) shows near obliteration of the true lumen by the false lumen. Arterial pressure was unmeasurable at the level of the aortic bifurcation. (c) Lateral aortogram shows narrowing of the true lumen (arrows) by the posterior false lumen, with the flap nearly occluding the origins of the celiac artery and SMA (arrowheads). (d) Digital image shows an Amplatz snare in the false lumen that was used as a target for flap puncture. The intravascular US transducer (IVUS) prevented proper positioning of the puncture needle, leading to puncture outside the aorta as indicated by the extravasated contrast material (black arrow). (e) Digital image demonstrates inflation of the dilatation balloon inside the snare, which has been pulled back over the wire to the site of the puncture through the dissection flap. This helps confirm correct positioning for fenestration. Stents were placed in the infrarenal aorta (coaxial Wallstents) and iliac arteries (Smartstent; Cordis, Miami, Fla). (f) Aortogram shows much better flow to the legs and renal arteries, including the left lower pole renal artery (arrow). Pressure was 114/65 mm Hg in the aorta, 115/65 mm Hg in the true lumen of the left external iliac artery, and 112/62 mm Hg in the false lumen at the same level. (g) Lateral aortogram shows that, in spite of the use of large coaxial stents, the false lumen still distorts the true lumen, although this did not cause a pressure gradient. (h) CT scan obtained over 3 months later shows continuing compression of the stent by the false lumen. However, the patient remains asymptomatic over 11 months after fenestration and no further intervention is currently planned.

View larger version (152K): [in a new window]   Figure 3h.  Branch vessel involvement in a patient with type B dissection who presented with severe abdominal and leg pain and severe hypertension. (a) Aortogram shows severe compression of the true lumen, with poor filling of the upper right renal artery (arrow) and reduced filling of the superior mesenteric artery (SMA). (b) Aortogram obtained at the level of the right lower pole renal artery (arrow) shows near obliteration of the true lumen by the false lumen. Arterial pressure was unmeasurable at the level of the aortic bifurcation. (c) Lateral aortogram shows narrowing of the true lumen (arrows) by the posterior false lumen, with the flap nearly occluding the origins of the celiac artery and SMA (arrowheads). (d) Digital image shows an Amplatz snare in the false lumen that was used as a target for flap puncture. The intravascular US transducer (IVUS) prevented proper positioning of the puncture needle, leading to puncture outside the aorta as indicated by the extravasated contrast material (black arrow). (e) Digital image demonstrates inflation of the dilatation balloon inside the snare, which has been pulled back over the wire to the site of the puncture through the dissection flap. This helps confirm correct positioning for fenestration. Stents were placed in the infrarenal aorta (coaxial Wallstents) and iliac arteries (Smartstent; Cordis, Miami, Fla). (f) Aortogram shows much better flow to the legs and renal arteries, including the left lower pole renal artery (arrow). Pressure was 114/65 mm Hg in the aorta, 115/65 mm Hg in the true lumen of the left external iliac artery, and 112/62 mm Hg in the false lumen at the same level. (g) Lateral aortogram shows that, in spite of the use of large coaxial stents, the false lumen still distorts the true lumen, although this did not cause a pressure gradient. (h) CT scan obtained over 3 months later shows continuing compression of the stent by the false lumen. However, the patient remains asymptomatic over 11 months after fenestration and no further intervention is currently planned.

View larger version (159K): [in a new window]   Figure 4a.  Renovascular hypertension in a patient with type B aortic dissection who presented with uncontrollable hypertension, reduced lower extremity pulses, and a rising creatinine level 2 weeks after dissection occurred. (a) CT scan shows the right renal artery arising from the false lumen (arrow) and near occlusion of the left renal artery by extension of the dissection flap (arrowhead). (b) Aortogram shows a common celiac artery-SMA origin, aortic obstruction, and faint filling of the obstructed left renal artery (arrow). (c) Angiogram demonstrates a right lower renal artery (arrow) arising from a very narrow true lumen of the infrarenal aorta, which was compressed by the posterior false lumen. Intravascular US-guided puncture of the flap was performed, and fenestration with a 20-mm balloon equalized lumen pressures. (d) Aortogram shows no obstruction of the right renal artery (arrow) but near occlusion of the left renal artery (cf a, b). (e) Selective left renal arteriogram shows narrowing of the true lumen by extension of the false lumen (arrow). A long, self-expanding Wallstent was deployed. (f) Digital image shows the Wallstent (arrow), which was effective in compressing the false lumen. (g) Digital image shows persistent obstruction of both iliac arteries. "Kissing" Wallstents were placed at the aortic bifurcation, and a third Wallstent was placed in the right external iliac artery. (h) Aortogram shows relief of the iliac artery obstruction. (i) On a CT angiogram obtained 9 months later, the stents are patent; after 15 months, the patient remains active and is taking two blood pressure medications.

View larger version (165K): [in a new window]   Figure 4b.  Renovascular hypertension in a patient with type B aortic dissection who presented with uncontrollable hypertension, reduced lower extremity pulses, and a rising creatinine level 2 weeks after dissection occurred. (a) CT scan shows the right renal artery arising from the false lumen (arrow) and near occlusion of the left renal artery by extension of the dissection flap (arrowhead). (b) Aortogram shows a common celiac artery-SMA origin, aortic obstruction, and faint filling of the obstructed left renal artery (arrow). (c) Angiogram demonstrates a right lower renal artery (arrow) arising from a very narrow true lumen of the infrarenal aorta, which was compressed by the posterior false lumen. Intravascular US-guided puncture of the flap was performed, and fenestration with a 20-mm balloon equalized lumen pressures. (d) Aortogram shows no obstruction of the right renal artery (arrow) but near occlusion of the left renal artery (cf a, b). (e) Selective left renal arteriogram shows narrowing of the true lumen by extension of the false lumen (arrow). A long, self-expanding Wallstent was deployed. (f) Digital image shows the Wallstent (arrow), which was effective in compressing the false lumen. (g) Digital image shows persistent obstruction of both iliac arteries. "Kissing" Wallstents were placed at the aortic bifurcation, and a third Wallstent was placed in the right external iliac artery. (h) Aortogram shows relief of the iliac artery obstruction. (i) On a CT angiogram obtained 9 months later, the stents are patent; after 15 months, the patient remains active and is taking two blood pressure medications.

View larger version (135K): [in a new window]   Figure 4c.  Renovascular hypertension in a patient with type B aortic dissection who presented with uncontrollable hypertension, reduced lower extremity pulses, and a rising creatinine level 2 weeks after dissection occurred. (a) CT scan shows the right renal artery arising from the false lumen (arrow) and near occlusion of the left renal artery by extension of the dissection flap (arrowhead). (b) Aortogram shows a common celiac artery-SMA origin, aortic obstruction, and faint filling of the obstructed left renal artery (arrow). (c) Angiogram demonstrates a right lower renal artery (arrow) arising from a very narrow true lumen of the infrarenal aorta, which was compressed by the posterior false lumen. Intravascular US-guided puncture of the flap was performed, and fenestration with a 20-mm balloon equalized lumen pressures. (d) Aortogram shows no obstruction of the right renal artery (arrow) but near occlusion of the left renal artery (cf a, b). (e) Selective left renal arteriogram shows narrowing of the true lumen by extension of the false lumen (arrow). A long, self-expanding Wallstent was deployed. (f) Digital image shows the Wallstent (arrow), which was effective in compressing the false lumen. (g) Digital image shows persistent obstruction of both iliac arteries. "Kissing" Wallstents were placed at the aortic bifurcation, and a third Wallstent was placed in the right external iliac artery. (h) Aortogram shows relief of the iliac artery obstruction. (i) On a CT angiogram obtained 9 months later, the stents are patent; after 15 months, the patient remains active and is taking two blood pressure medications.

View larger version (166K): [in a new window]   Figure 4d.  Renovascular hypertension in a patient with type B aortic dissection who presented with uncontrollable hypertension, reduced lower extremity pulses, and a rising creatinine level 2 weeks after dissection occurred. (a) CT scan shows the right renal artery arising from the false lumen (arrow) and near occlusion of the left renal artery by extension of the dissection flap (arrowhead). (b) Aortogram shows a common celiac artery-SMA origin, aortic obstruction, and faint filling of the obstructed left renal artery (arrow). (c) Angiogram demonstrates a right lower renal artery (arrow) arising from a very narrow true lumen of the infrarenal aorta, which was compressed by the posterior false lumen. Intravascular US-guided puncture of the flap was performed, and fenestration with a 20-mm balloon equalized lumen pressures. (d) Aortogram shows no obstruction of the right renal artery (arrow) but near occlusion of the left renal artery (cf a, b). (e) Selective left renal arteriogram shows narrowing of the true lumen by extension of the false lumen (arrow). A long, self-expanding Wallstent was deployed. (f) Digital image shows the Wallstent (arrow), which was effective in compressing the false lumen. (g) Digital image shows persistent obstruction of both iliac arteries. "Kissing" Wallstents were placed at the aortic bifurcation, and a third Wallstent was placed in the right external iliac artery. (h) Aortogram shows relief of the iliac artery obstruction. (i) On a CT angiogram obtained 9 months later, the stents are patent; after 15 months, the patient remains active and is taking two blood pressure medications.

View larger version (164K): [in a new window]   Figure 4e.  Renovascular hypertension in a patient with type B aortic dissection who presented with uncontrollable hypertension, reduced lower extremity pulses, and a rising creatinine level 2 weeks after dissection occurred. (a) CT scan shows the right renal artery arising from the false lumen (arrow) and near occlusion of the left renal artery by extension of the dissection flap (arrowhead). (b) Aortogram shows a common celiac artery-SMA origin, aortic obstruction, and faint filling of the obstructed left renal artery (arrow). (c) Angiogram demonstrates a right lower renal artery (arrow) arising from a very narrow true lumen of the infrarenal aorta, which was compressed by the posterior false lumen. Intravascular US-guided puncture of the flap was performed, and fenestration with a 20-mm balloon equalized lumen pressures. (d) Aortogram shows no obstruction of the right renal artery (arrow) but near occlusion of the left renal artery (cf a, b). (e) Selective left renal arteriogram shows narrowing of the true lumen by extension of the false lumen (arrow). A long, self-expanding Wallstent was deployed. (f) Digital image shows the Wallstent (arrow), which was effective in compressing the false lumen. (g) Digital image shows persistent obstruction of both iliac arteries. "Kissing" Wallstents were placed at the aortic bifurcation, and a third Wallstent was placed in the right external iliac artery. (h) Aortogram shows relief of the iliac artery obstruction. (i) On a CT angiogram obtained 9 months later, the stents are patent; after 15 months, the patient remains active and is taking two blood pressure medications.

View larger version (149K): [in a new window]   Figure 4f.  Renovascular hypertension in a patient with type B aortic dissection who presented with uncontrollable hypertension, reduced lower extremity pulses, and a rising creatinine level 2 weeks after dissection occurred. (a) CT scan shows the right renal artery arising from the false lumen (arrow) and near occlusion of the left renal artery by extension of the dissection flap (arrowhead). (b) Aortogram shows a common celiac artery-SMA origin, aortic obstruction, and faint filling of the obstructed left renal artery (arrow). (c) Angiogram demonstrates a right lower renal artery (arrow) arising from a very narrow true lumen of the infrarenal aorta, which was compressed by the posterior false lumen. Intravascular US-guided puncture of the flap was performed, and fenestration with a 20-mm balloon equalized lumen pressures. (d) Aortogram shows no obstruction of the right renal artery (arrow) but near occlusion of the left renal artery (cf a, b). (e) Selective left renal arteriogram shows narrowing of the true lumen by extension of the false lumen (arrow). A long, self-expanding Wallstent was deployed. (f) Digital image shows the Wallstent (arrow), which was effective in compressing the false lumen. (g) Digital image shows persistent obstruction of both iliac arteries. "Kissing" Wallstents were placed at the aortic bifurcation, and a third Wallstent was placed in the right external iliac artery. (h) Aortogram shows relief of the iliac artery obstruction. (i) On a CT angiogram obtained 9 months later, the stents are patent; after 15 months, the patient remains active and is taking two blood pressure medications.

View larger version (174K): [in a new window]   Figure 4g.  Renovascular hypertension in a patient with type B aortic dissection who presented with uncontrollable hypertension, reduced lower extremity pulses, and a rising creatinine level 2 weeks after dissection occurred. (a) CT scan shows the right renal artery arising from the false lumen (arrow) and near occlusion of the left renal artery by extension of the dissection flap (arrowhead). (b) Aortogram shows a common celiac artery-SMA origin, aortic obstruction, and faint filling of the obstructed left renal artery (arrow). (c) Angiogram demonstrates a right lower renal artery (arrow) arising from a very narrow true lumen of the infrarenal aorta, which was compressed by the posterior false lumen. Intravascular US-guided puncture of the flap was performed, and fenestration with a 20-mm balloon equalized lumen pressures. (d) Aortogram shows no obstruction of the right renal artery (arrow) but near occlusion of the left renal artery (cf a, b). (e) Selective left renal arteriogram shows narrowing of the true lumen by extension of the false lumen (arrow). A long, self-expanding Wallstent was deployed. (f) Digital image shows the Wallstent (arrow), which was effective in compressing the false lumen. (g) Digital image shows persistent obstruction of both iliac arteries. "Kissing" Wallstents were placed at the aortic bifurcation, and a third Wallstent was placed in the right external iliac artery. (h) Aortogram shows relief of the iliac artery obstruction. (i) On a CT angiogram obtained 9 months later, the stents are patent; after 15 months, the patient remains active and is taking two blood pressure medications.

View larger version (164K): [in a new window]   Figure 4h.  Renovascular hypertension in a patient with type B aortic dissection who presented with uncontrollable hypertension, reduced lower extremity pulses, and a rising creatinine level 2 weeks after dissection occurred. (a) CT scan shows the right renal artery arising from the false lumen (arrow) and near occlusion of the left renal artery by extension of the dissection flap (arrowhead). (b) Aortogram shows a common celiac artery-SMA origin, aortic obstruction, and faint filling of the obstructed left renal artery (arrow). (c) Angiogram demonstrates a right lower renal artery (arrow) arising from a very narrow true lumen of the infrarenal aorta, which was compressed by the posterior false lumen. Intravascular US-guided puncture of the flap was performed, and fenestration with a 20-mm balloon equalized lumen pressures. (d) Aortogram shows no obstruction of the right renal artery (arrow) but near occlusion of the left renal artery (cf a, b). (e) Selective left renal arteriogram shows narrowing of the true lumen by extension of the false lumen (arrow). A long, self-expanding Wallstent was deployed. (f) Digital image shows the Wallstent (arrow), which was effective in compressing the false lumen. (g) Digital image shows persistent obstruction of both iliac arteries. "Kissing" Wallstents were placed at the aortic bifurcation, and a third Wallstent was placed in the right external iliac artery. (h) Aortogram shows relief of the iliac artery obstruction. (i) On a CT angiogram obtained 9 months later, the stents are patent; after 15 months, the patient remains active and is taking two blood pressure medications.

View larger version (140K): [in a new window]   Figure 4i.  Renovascular hypertension in a patient with type B aortic dissection who presented with uncontrollable hypertension, reduced lower extremity pulses, and a rising creatinine level 2 weeks after dissection occurred. (a) CT scan shows the right renal artery arising from the false lumen (arrow) and near occlusion of the left renal artery by extension of the dissection flap (arrowhead). (b) Aortogram shows a common celiac artery-SMA origin, aortic obstruction, and faint filling of the obstructed left renal artery (arrow). (c) Angiogram demonstrates a right lower renal artery (arrow) arising from a very narrow true lumen of the infrarenal aorta, which was compressed by the posterior false lumen. Intravascular US-guided puncture of the flap was performed, and fenestration with a 20-mm balloon equalized lumen pressures. (d) Aortogram shows no obstruction of the right renal artery (arrow) but near occlusion of the left renal artery (cf a, b). (e) Selective left renal arteriogram shows narrowing of the true lumen by extension of the false lumen (arrow). A long, self-expanding Wallstent was deployed. (f) Digital image shows the Wallstent (arrow), which was effective in compressing the false lumen. (g) Digital image shows persistent obstruction of both iliac arteries. "Kissing" Wallstents were placed at the aortic bifurcation, and a third Wallstent was placed in the right external iliac artery. (h) Aortogram shows relief of the iliac artery obstruction. (i) On a CT angiogram obtained 9 months later, the stents are patent; after 15 months, the patient remains active and is taking two blood pressure medications.