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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.
