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Hybrid Repair of Chronic Stanford Type B Aortic Dissection with Expanding Arch Aneurysm
Sheena Chen1, Kyongjune Benjamin Lee1, Bao-Ngoc Nguyen1
1The George Washington University Hospital, Washington, DC. Gregory.trachiotis@va.gov.
Insights
A complex case of chronic Stanford type B aortic dissection (TBAD) with an expanding aneurysm was successfully treated with a multi-stage hybrid repair. This approach offers a viable solution for challenging TBAD cases unresponsive to medical management.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Aortic Disease
Background:
- Chronic Stanford type B aortic dissection (TBAD) management is challenging, often leading to complications, morbidity, and mortality.
- Current guidelines for intervening in complicated chronic TBAD are lacking.
- Aneurysmal degeneration of the false lumen in chronic TBAD presents a significant therapeutic hurdle.
Observation:
- A patient with chronic TBAD presented with an expanding false lumen aneurysm and distal fenestrations.
- Medical management failed to halt the aneurysmal progression.
- The complexity necessitated a multi-stage hybrid surgical approach.
Findings:
- The patient underwent a staged hybrid repair involving aortic debranching and endovascular grafting.
- The procedure included ascending aorta to great vessel bypasses and thoracic/abdominal endovascular repair.
- The patient demonstrated a successful recovery with no aneurysm expansion at 12-month follow-up.
Implications:
- Multi-stage hybrid repair is a feasible and effective strategy for complex chronic TBAD with aneurysmal degeneration.
- This approach may be crucial for cases refractory to standard endovascular techniques or medical management.
- Further research into hybrid techniques for complex aortic dissections is warranted.
Purpose:
The management of patients with chronic Stanford type B aortic dissection who develop complications requires intervention without clear guidelines. Chronic aortic dissection is difficult to treat and often leads to significant morbidity and mortality. We report a complex case of chronic Stanford type B aortic dissection (TBAD) with an expanding false lumen aneurysm and distal fenestrations that required a multi-stage hybrid repair.
Technique:
The patient first underwent a median sternotomy for the ascending aorta to the innominate artery and innominate artery to the left carotid artery bypass, followed by a left carotid to left axillary artery bypass. Due to continued aneurysmal growth, the patient ultimately underwent total cervical and abdominal aortic debranching as well as thoracic and abdominal endovascular grafting with iliac excluders. The patient recovered well after the surgery and had no further expansion of the aneurysm at 12-month follow up.
Conclusion:
Endovascular repairs have been the mainstay of chronic TBAD repair, but hybrid approaches may be necessary for difficult repairs. A multi-stage hybrid repair approach has been successful in a patient who had a chronic type B aortic dissection with aneurysmal degeneration that failed medical management.
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