Endovascular Treatment of a Complicated Type B Acute Aortic Dissection with 3-D ultrasound Control

Acute type B aortic dissection (ATBAD), identified within 2 weeks of symptom onset, accounts for 25%-40% of all aortic dissections. Approximately 25% of patients presenting with ATBAD are complicated at admission by malperfusion syndrome or hemodynamic instability, resulting in a high risk of early death when untreated.

We present a case of a patient with a complicated type B dissection treated by an endovascular technique with control of the sealing zone with transesophageal Echocardiogram (TEE) and 3-D images.

A 56-year-old patient was admitted to the intensive care unit for having a type B aortic dissection complicated by persistent chest pain and uncontrolled hypertension. We perform a TEVAR (thoracic endovascular aortic repair) with a GORE® TAG® conformable thoracic stent graft with active control system to seal the primary entry tear, which covered the left subclavian artery. The origin of the left subclavian artery was covered by the stent graft and a vascular plug was put in place, to avoid endoleak. The procedure was performed with transesophageal echocardiogram with 3-D images to determine if the stent graft was in the true lumen.

The treatment of acute, complicated type B aortic dissection has evolved in the past several years. Thoracic endovascular aortic repair when anatomy is suitable, has been regarded as the preferable treatment to seal the primary entry tear, redirect and re-establish adequate true lumen flow, and thereby promote aortic remodeling. The availability of TEVAR, albeit applied until recently as an off- -label treatment, has clearly produced better results than procedures such as open surgical or endovascular fenestration. However, the results of this treatment may improve when associated with other imaging tests. The TEE has a high performance in the diagnosis of this pathology, especially in regard to the detection of the flap and the two lumens, as well as for the calculation of the size of the entrance tear. It presents an added value in the endovascular treatment, since it helps in the implantation of the devices both for the location of the true lumen, its definitive position and the result of the procedure. TEVAR is the preferred treatment for acute, complicated type B aortic dissection with improved late survival and positive aortic remodelling. The efficacy of this treatment is significantly increased in association with other imaging techniques such as transesophageal echography.