Balloon Fracture Fenestration after Frozen Elephant Trunk Deployment to Eliminate Retrograde False-Lumen Perfusion in...

Arch or proximal descending aortic aneurysms complicated by Stanford type B aortic dissection (TBAD) may require extensive open repair with an open proximal anastomosis. Although a staged modified elephant trunk strategy is a reasonable option, the need to undergo two major operations is burdensome. The frozen elephant trunk (FET) technique enables concomitant treatment of the descending aorta after arch replacement; however, persistent retrograde false-lumen perfusion may result in incomplete aneurysm exclusion and inadequate aortic remodeling. We report a single-stage approach using adjunctive balloon fracture fenestration after FET deployment.

A 78-year-old man was referred 63 days after TBAD onset. CT demonstrated a 60-mm enlargement of the proximal descending aorta immediately distal to the left subclavian artery, a 37-mm distal segment, and enlargement of the ascending aorta to 42 mm, making standard thoracic endovascular aortic repair unsuitable. Total arch replacement using FET was performed, followed by balloon expansion of the FET to fracture the dissection flap, after which angiography demonstrated resolution of the endoleak. At 6 months, CT revealed distal stent graft-induced new entry, along with aneurysm shrinkage, complete thrombosis, and no communication between the proximal and distal false lumens.

Balloon fracture fenestration applied to total arch replacement with FET may interrupt retrograde false-lumen perfusion and enhance distal sealing in selected TBAD-associated arch or proximal descending aneurysms. However, careful vigilance is required to mitigate potential complications, including distal stent graft-induced new entry and spinal cord ischemia. This approach may mitigate a major limitation of staged repair, namely the risk of interval rupture while awaiting completion of the second-stage procedure.