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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).

	Abstract

Top Abstract Introduction Manifestations and Complications... Aortic Fenestration Summary References

 
The management of aortic dissection can be challenging. Most cases of acute type A dissection are managed surgically. Most cases of acute type B dissection are managed medically, although open surgery or stent-graft placement is sometimes performed. Patients with type B or surgically treated type A dissection may develop vascular complications such as mesenteric or peripheral ischemia, which cannot be managed medically. Aortic fenestration is a method for decompressing the hypertensive false lumen by creating a hole in the distal part of the dissection flap. This procedure allows outflow from the false lumen, thereby reducing intraluminal pressure, relieving branch vessel obstruction, and reducing the risk of extension of the dissection. Urgent revascularization is required to correct mesenteric and renal ischemia and to reestablish distal perfusion if there is resting ischemia. Few operators will acquire extensive personal experience with percutaneous aortic fenestration. Nevertheless, with a good understanding of the pathologic condition, careful demonstration of the anatomy, good technical skills, and access to high-quality imaging (including intravascular ultrasonography) and the requisite equipment, most interventional radiologists skilled in arterial interventions should be capable of performing this procedure. However, because further interventions are frequently required, the radiologist needs to maintain contact with the patient to ensure timely treatment of any subsequent complications.

© RSNA, 2005

	Introduction

Top Abstract Introduction Manifestations and Complications... Aortic Fenestration Summary References

 
Aortic dissection is the most common catastrophic disorder to affect the aorta, being twice as common as rupture of the abdominal aorta. The range of manifestations is extensive, and misdiagnosis is common. The mortality rate for untreated patients is reported to be as high as 1%–2% per hour during the first 48 hours after development of symptoms. Accurate diagnosis and staging is relatively easy with good-quality echocardiography, contrast material–enhanced computed tomography (CT) or CT angiography, or magnetic resonance (MR) imaging or MR angiography (1–3). Appropriate use of these techniques requires a high degree of suspicion for aortic dissection, which cannot be diagnosed or excluded on the basis of chest radiographic findings (4). In most situations, aortography is required only (a) if good-quality noninvasive imaging is not available, or (b) to guide percutaneous intervention.

In general, acute dissections originating in the ascending aorta (DeBakey types 1 and 2, Stanford type A) are best treated with urgent surgery, with resection of the ascending aorta, tube replacement (polyethylene terephthalate [Dacron; DuPont, Wilmington, Del] graft), and resuspension or replacement of the aortic valve if it is involved. Conversely, in general, acute dissections originating in the descending aorta (DeBakey type 3, Stanford type B) are best treated medically, provided (a) medical treatment is successful in stabilizing the dissection and controlling hypertension, and (b) there are no other complications. In some unstable situations, repair of the descending aorta with surgery or percutaneous stent-graft placement is worthwhile (5–7). In patients with chronic aortic dissection who are in stable condition, surgery is indicated if the patient is symptomatic or has an aortic diameter greater than 6 cm (>5–5.5 cm in patients with Marfan syndrome). Complications may occur or persist following surgical treatment or may develop in spite of medical treatment (8). Significant branch vessel compromise can occur in up to one-third of cases (8–10). Some of these complications can be corrected or stabilized using the technique of aortic fenestration (11,12).

Compromised flow to branch vessels is often due to compression of the true lumen by the false lumen, which is usually at a higher pressure than the true lumen. Fenestration is a technique in which a hole is created in the dissection flap, thereby allowing outflow from the false lumen. Creating this outflow decompresses the false lumen, reduces the risk of further dissection, and relieves the obstruction of branch vessels due to compression of the true lumen by the false lumen, although stent placement may also be required. In this article, we describe the manifestations and complications of aortic dissection. We also discuss and illustrate the use of percutaneous fenestration for aortic dissection in terms of history, rationale, and technique (preparation, imaging guidance, treatment of branch vessel obstruction, and outcomes). The article provides insights into patient selection for aortic fenestration and serves as an introduction for those with appropriate skills who want to perform this procedure.

	Manifestations and Complications of Acute Aortic Dissection

Top Abstract Introduction Manifestations and Complications... Aortic Fenestration Summary References

 
The typical manifestation of acute aortic dissection is the sudden development of severe "tearing" or "ripping" chest pain radiating to the back. Other manifestations may be less obvious and are listed in Table 1. Awareness of this potential diagnosis should be increased for patients with an associated condition such as Marfan syndrome, Ehlers-Danlos syndrome, systemic lupus erythematosus, cocaine use, and aortitis (due to Takayasu arteritis, giant cell arteritis, and polyarteritis nodosa). Aortic dissection is also an uncommon but well-recognized complication following aortic manipulation or clamping during aortic valve and coronary artery bypass surgery (Fig 1). Although this condition is usually recognized and corrected intraoperatively, it is not always possible to do so, and subsequent treatment may be required. Aortic dissection can also complicate invasive angiographic and interventional procedures. These dissections are usually self-limiting but rarely may require treatment. There are a variety of complications of aortic dissection that may require specific treatment, in addition to the usual recommendations: surgery (for type A dissection) and antihypertensive medication (for type B dissection) mentioned earlier.

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 fenes