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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 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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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 this window] [in a new window] [Download PPT slide]   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.

	Aortic Fenestration

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

Although experience with percutaneous fenestration remains limited, this procedure is recognized as having an important role in treating patients with significant branch artery compromise, provided adequate imaging quality and technical skill are available. Fenestration can be performed in patients with type B dissection or in those with type A dissection who have been treated with surgery or stent-graft placement but continue to have distal branch artery compromise. In patients with a stable and uncomplicated dissection, there is little to be gained by performing fenestration; rather, the procedure is indicated in patients with significant mesenteric, renal, or peripheral ischemia or renovascular hypertension due to the dissection (Table 4). It should be remembered that these patients may appear to be in stable condition. However, the wall of the aorta is diseased, and even careful manipulation (whether during surgery or with percutaneous intervention) can precipitate a disastrous extension of the flap or even aortic rupture (13).

In patients with branch vessel obstruction by the false lumen, stent placement can restore patency of the involved artery. However, to prevent extension of the dissection beyond the stent, decompression of the false lumen is required. Alternatively, sometimes decompression of the false lumen alone may allow restoration of vessel patency, as when perfusion returns after spontaneous reentry of the dissection into the true lumen. The observation that spontaneous reentry could lead to reperfusion gave impetus to the development of the first surgical fenestration, and percutaneous fenestration techniques followed.

Technique
Preparation.— Aortic fenestration is potentially one of the most difficult, prolonged, and, for the patient, hazardous percutaneous procedures. Unlike with aortic stent-graft placement, few clinicians develop personal experience involving more than a handful of cases. Therefore, expertise in handling all the potential devices (intravascular US, angioplasty balloons, stents, snares, occlusion balloons, transseptal needles) that might be required in rapid succession during the procedure is recommended, not just for the operator but also for assistants. Whether having a cardiothoracic surgeon on standby is appropriate will depend on local conditions. We strongly advise developing good relationships with cardiothoracic and vascular surgeons—for many reasons—and discussing the management of the case with them in advance. If the fenestration goes catastrophically wrong, it is quite possible that surgical rescue may not be possible. The patient and family need to be fully aware of this.

The key to successful aortic fenestration is careful preparation with accurate vascular evaluation before starting the procedure. Initial evaluation requires demonstration of the upper and lower ends of the dissection, assessment of the cause and degree of obstruction of the involved branch vessels, and determination of whether branch vessels are fed by the true lumen or the false lumen. If obstruction is due to a flap, it should be determined whether the flap and false lumen extend into the vessel or the flap prolapses over the vessel origin. The precise relationship of each major branch vessel to the dissection flap should be known before starting the procedure. The relative position and size of the true and false lumina should be assessed. The false lumen can be identified by tracing it from the entry site and by noting its larger size and its lesser contrast material enhancement. All of these questions should be answerable with good-quality MR angiography, CT angiography, or US. Given the current state of the art, we prefer CT angiography, which also allows definition of the relationship of the vessels to adjacent anatomy and demonstrates angulation of branch vessels that may make catheter manipulation difficult. CT angiography should be supplemented with intravascular US when necessary for staging as well as for guiding the intervention. Intravascular US is also valuable for assessing changes in anatomy that occur as a consequence of the interventions.

Ideally, the patient should be hemodynamically stable and any metabolic or hemodynamic problems corrected, although the urgency of the situation may prevent this. Patients should be well hydrated and should be pretreated with N-acetyl-cysteine if there is renal insufficiency. The patient should be normotensive if possible. It should be remembered that renal insufficiency or metabolic disturbances due to mesenteric ischemia are usually a manifestation of branch vessel obstruction. Fenestration, with or without stent placement, provides the best chance of reversing these changes; therefore, the procedure should not be inappropriately delayed by ineffective medical attempts to reverse these abnormalities. Maintaining normal blood pressure may require monitored titration of intravenous medications such as nitroprusside. This task should be delegated to a skilled intensive care unit (ICU) nurse or member of the ICU or anesthesiology team. Unless there is a specific reason for intubation and general anesthesia, aortic fenestration can be performed with intravenous conscious sedation. The indications for general anesthesia include uncontrolled hypertension, patient discomfort, and poor patient cooperation.

Imaging Guidance.— There are several techniques for guiding aortic fenestration and, in particular, for guiding puncture of the flap from the true to the false lumen. Some investigators have reported using a loop snare or basket introduced from the arm into the false lumen as a target (14). Others rely on multiplanar angiography, whereas some use transesophageal echocardiographic guidance (15), although the latter limits imaging of the thoracic and upper abdominal aorta. In our experience, intravascular US provides the best guidance (Fig 1) and increases operator confidence in puncturing the flap (16). Arterial access is established from both common femoral arteries (CFAs). If there are no palpable pulses, a US-guided puncture is performed. Typically, the false lumen does not extend as far as the CFA, and puncture at this level usually provides access to the true lumen. If there is a proximal obstruction caused by expansion of the false lumen, a soft J-tip guide wire should be used to advance catheters and sheaths into the true lumen of the aorta. We usually choose to advance the intravascular US catheter from the left CFA, unless there is an anatomic reason not to do so. This approach keeps the intravascular US cables out of the work area. The intravascular US examination should extend from the left subclavian artery to the CFA (Table 5). Intravascular US is helpful for confirming entry into the true lumen (Fig 1e), which can also be differentiated from the false lumen in that it usually has a smaller diameter, demonstrates earlier contrast opacification at angiography, and has a lower pressure.

When a puncture of the dissection flap is required, a curved, hollow metal needle acts as a guide. Various needles can be used depending on availability, including Brockenborough and Colapinto needles. We use equipment from the Rösch-Uchida transjugular liver access set (Cook). The needle is advanced through a suitably-sized guide sheath chosen to allow introduction of the correct-sized balloon for fenestration. The balloon will usually be at least 15 mm in diameter. The outer part of the needle is introduced into the sheath over a stiff guide wire. A hydrophilic wire should not be used because passage of the needle may strip off the outer wire coat. The needle is advanced above the level to be punctured. The intravascular US transducer is then positioned at the intended level of the puncture, usually in the infrarenal aorta, although fenestrations at several levels may be required to achieve equalization of pressures. The aim is to produce unobstructed outflow from the false lumen, which is usually either a blind sac or tapers to a small spontaneous fenestration. This causes a "ram" effect; hence, the higher pressures usually seen in the false lumen.

The level chosen for puncture should allow enough space for the stylet to pass through the flap without puncturing the far wall of the aorta. The direction of the puncture should be away from the origin of any major branch vessels. The metal stylet, with a coaxially mounted 5-F catheter, is inserted to just inside the needle tip. Under fluoroscopic and intravascular US control, the needle assembly is pulled back and rotated until it is seen at intravascular US indenting the flap at the point required for puncture (Fig 1g). The stylet is advanced 1–2 cm through the flap; this penetration may be visible at intravascular US. The stylet is removed and the 5-F catheter left in position across the flap. A stiff J-tip guide wire (Rosen or Amplatz wire, Cook) is advanced well into the false lumen. A catheter is introduced into the false lumen to confirm satisfactory entry and measure false lumen pressure. With an over-the-wire exchange technique, an appropriate-sized (15–25-mm), low-profile balloon is inserted through the sheath and, under intravascular US guidance, positioned across the flap and inflated (Fig 1h).

One should not attempt to perform a Rashkind procedure by pulling on the inflated balloon; this risks rupturing the aorta or extending the flap. The aim is to perform a dilation to create a hole in the center of the flap. After the fenestration is created, the pressures within the true and false lumina are compared. If there is a residual gradient, consider whether to enlarge the fenestration with a larger balloon or to create a second fenestration. The maximum size of the balloon is limited by the need for percutaneous access and also to avoid overdilating the diseased aorta and worsening the dissection. For this reason, we recommend limiting the balloon size to no more than 20 mm (80% of the diameter of the average abdominal aorta [25 mm]); if a pressure gradient persists, we then perform a second fenestration. The aim is to create an unobstructed outflow from the false lumen with little or no pressure gradient (we aim for 5 mm Hg or less).

Patients with aortic dissection have a potentially lethal condition. They are often desperately ill, particularly when there is symptomatic branch vessel obstruction. In these situations, medical treatment alone is unlikely to be adequate. The longer the delay, the worse the prognosis; early intervention is required. Whether intervention consists of percutaneous fenestration or surgical fenestration depends on local resources; in either case, a delay of 24 hours can be lethal.

Treatment of Branch Vessel Obstruction.— Once adequate aortic fenestration has been achieved, the degree of obstruction of the major branch vessels should be reassessed with intravascular US, angiography, and pressure measurements. Even if the false lumen is decompressed, significant branch vessel obstruction by the flap or by extension of the false lumen may persist. Symptomatic and hemodynamically more severe lesions should be treated first by placing a stent in the true lumen. If multiple vessels require treatment, the most sensitive areas should be addressed first. For this reason, priority should be given to SMA or celiac artery obstruction, followed by at least one kidney; this is because the gut has the least tolerance for underperfusion. It is usually easiest to place a stent in the origin of the SMA. Once the bowel is adequately perfused (which should be the case because compromise of the celiac artery is reasonably well tolerated if the SMA is patent), the next most urgent target is at least one renal artery to preserve renal function (survival with one kidney is possible, whereas severe mesenteric ischemia is not survivable).

After the most critical obstructions have been corrected, less urgent priorities for revascularization can be addressed. These lesser priorities include any remaining compromised renal arteries, followed by the iliac arteries and subclinical obstructions. The choice of stent will depend on the anatomy. We generally use balloon-expandable stents to treat visceral branch involvement. Self-expanding stents are preferred for aortic or iliac artery stent placement. For stent placement in an obstructed aorta, positioning the stent across the mouth of any branch vessels or of a fenestration should be avoided if possible. In this setting, the use of a stent with large cells is advisable to reduce the risk of branch vessel occlusion. Although we have not used Gianturco-Rösch stents (Cook-Z stent, Cook) in this context, the very large cell size of these stents may be useful when more commonly used stents fail or are thought to be inappropriate. The aim of aortic stent placement is to relieve obstruction rather than to completely close the false lumen. Adequate expansion of the true lumen may require coaxial deployment of several stents.

After successful fenestration and branch vessel revascularization, pressures are checked and completion intravascular US and aortography performed. Particular attention should be paid to the possible presence of branch vessel thrombosis or distal embolization. In patients with mesenteric ischemia, there should be a careful assessment of gut viability. Persistent pain or metabolic acidosis may require laparotomy to assess for areas of mesenteric infarction. Prolonged peripheral ischemia may require immediate fasciotomy to prevent compartment syndrome.

When the percutaneous procedure has been completed, the arterial sheaths are removed. Because the required arterial punctures are relatively large, it may be appropriate to use a closure device. It should be remembered that early reintervention may be required. Therefore, an extravascular closure device that allows early repuncture should be used (Duett, Vascular Solutions, Minneapolis, Minn; Vasoseal Elite, Datascope, Mahwah, NJ). We believe that it is more appropriate to use prolonged manual compression augmented by a compression device such as Femostop (RADI Medical Systems, Reading, Mass) or Safeguard (Datascope), since repeat intervention may be required within hours. In all of the cases discussed in this article, hemostasis was achieved with manual compression.

Other methods for guiding fenestration have been described that make use of loop snares (Fig 3) or stone baskets (14) introduced into the false lumen as a target for flap puncture or pure angiographic guidance. The use of an inflated balloon in the false lumen as a target has also been described (17), as has a technique in which crossed guide wires are introduced through a sheath to cut the flap (18). Another approach is to pass a guide wire through a defect in the flap, then snare and pull the wire, cutting through the flap (19). We think these guide wire methods are less reliable, more complex, or more hazardous than the procedure described in this article. Infrequently, there may be no alternative but to puncture the flap without intravascular US guidance or a target in the false lumen. If this alternative is truly necessary, it should be performed on the basis of CT findings and angiographic profiling of the flap.

Outcomes.— It is difficult to give a good account of outcomes because there are no large published prospective studies; a variety of techniques and indications characterized the approximately 117 cases reported to date. Even the largest study reported on only 40 patients (20), and there is a paucity of long-term follow-up data. Overall technical success in revascularization exceeds 90% (20–22). Visceral artery involvement is predictive of a poor outcome and proves fatal in up to one-third of patients due to the extent of vascular involvement and the development of multiorgan failure (20). There is little consensus regarding the frequency with which fenestration is required or whether stent placement alone is adequate. It seems to be agreed that fenestration alone is inadequate and that stent placement is required to address any fixed or dynamic obstruction. Rupture of the dissected aorta, although a real risk, seems to be an uncommon procedural complication, but there is still potential for extension of the dissection in spite of fenestration (13).

To our knowledge, there has been no prospective study comparing percutaneous with surgical fenestration. The results of surgical fenestration seem to be worse, with an operative mortality rate of 43% for patients who undergo emergency surgical fenestration (23). The role of fenestration in the era of stent-graft placement is also unclear. Restoring normal pressure to the false lumen may be beneficial, and restoring branch vessel patency may be easier after fenestration. There may be a role for both approaches, with stent-graft placement being used to obliterate the false lumen after decompression and, in suitable cases, to cover the tear leading to the false lumen (24).

	Summary

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

 
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, and good technical skills, this technique should be within the scope of most interventional radiologists skilled in arterial interventions. Access to good-quality imaging (including intravascular US) and to the necessary equipment is essential. Revascularization of all severely impaired areas is crucial, even if the procedure is prolonged, to correct mesenteric and renal ischemia and to reestablish distal perfusion if there is resting limb ischemia. It should be kept in mind that the aorta remains diseased and requires lifelong surveillance and that further interventions are frequently required (Fig 2). After a successful procedure, the radiologist needs to maintain contact with the patient to ensure timely treatment of any subsequent complications.

	Footnotes

 
Abbreviations: CFA = common femoral artery, SMA = superior mesenteric artery

Editor’s Note: None of the devices described in this article has been approved by the U.S. Food and Drug Administration for use in aortic fenestration; however, the devices have been approved for use in situations that may be components of fenestration. In addition, at this time there is no Current Procedural Terminology code to describe aortic fenestration.

	References

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

 

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