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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.
