Sandwich Technique for Iliac Aneurysm Rupture After Treatment of Iatrogenic Type B Aortic Dissection: A Case Report

Type B iatrogenic acute aortic dissection (IAAD) is a rare complication of diagnostic or interventional cardiac procedures. The STent Assisted Balloon Induced intimaL dISruption and rElamination in aortic dissection repair (STABILISE) technique is being increasingly used for the treatment of complicated aortic dissections. However, hemodynamic changes and the pre-existence of aneurysmal arteries could lead to "unexpected" complications.

This case report shows how rescue techniques can be employed in response to such challenging handling situations, especially in emergency settings. We describe the case of a patient with bilateral common iliac artery (CIA) aneurysm subjected to coronary angiography followed by iatrogenic type B acute aortic dissection (TBAAD), treated with the STABILISE technique, further complicated with left iliac aneurysm rupture on the 9th postoperative day. During aortic bifurcated endograft deployment, the contralateral gate opened into the false lumen (FL), and it was impossible to re-enter the true lumen (TL).

As a rescue solution, an iliac extension was deployed parallel to the main body, using the sandwich technique, extending to the external iliac artery. Before deployment, the left hypogastric artery was embolized with coils. Despite the false lumen of the right iliac aneurysm being perfused by the patent contralateral leg, the ruptured aneurysm was excluded. At a later stage, the right hypogastric artery was embolized with several coils, and the gate was embolized using an Amplatzer™ Vascular Plug.

In complex cases, especially with dissections, the unexpected is around the corner. The use of off-the-shelf devices, knowledge of rescue techniques as Parallel Graft Technique (PGT) and experience in applying them can resolve situations that might otherwise be disastrous.