History
A male patient in his 60s had a history of hypertension and morbid obesity who presented to RUSH with sudden onset chest pain. He was diagnosed with acute type B aortic dissection, which was initially managed with anti-impulse control. He was discharged to home with several new blood pressure medications.
Presentation and Examination
His computed tomography revealed several high-risk features, including a compressed true lumen with a large fenestration and early aneurysmal degeneration of the descending thoracic aorta.
About type B aortic dissection
An aortic dissection is a tear in the intima and media layers of the aorta. These can cause malperfusion or, in some cases, aortic rupture. Aortic dissections can affect approximately three in 100,000 patients annually in the United States. Initial medical management is critically important for uncomplicated type B aortic dissection. Thoracic endovascular aortic repair (TEVAR) is a mainstay of treatment when an intervention is performed. Procedural planning centers on patient status, extent of the dissection and branch vessel involvement.
About GORE Thoracic Branch Endoprosthesis
From the Food and Drug Administration
Approved by the FDA in 2022, the GORE Thoracic Branch Endoprosthesis (GORE TBE) is designed to repair the damage to the descending thoracic aorta. It consists of three implantable stent grafts with their own catheter-based delivery system. The GORE TBE is implanted in the descending thoracic aorta and into the left subclavian artery to allow blood to keep flowing past the aorta’s damaged or diseased parts.
Treatment
I performed a TEVAR with a subclavian branch device. I began the procedure by exposing the left brachial artery; a 5 Fr 70 cm sheath was inserted, and the tip was placed at the left subclavian artery (SCA) origin. I then obtained percutaneous access to both common femoral arteries.
I accessed the ascending thoracic by a double curved Lunderquist wire. An IVUS was run over the Lunderquist wire, which confirmed wire location within the true lumen.
Then, the left femoral access was upsized to a 26 Fr Dryseal sheath. A 450 cm Jag wire was advanced from the left brachial artery and the wire was advanced to the descending thoracic aorta. An Indy OTW snare was used to externalize it through the left femoral artery access.
I advanced a GORE TBE device to the distal aortic arch without a wire wrap. Once the supra-aortic trunk vessels were visualized, the GORE TBE device was deployed at the intended location. Then, the side branch component was delivered with the guide of the 5 Fr sheath from the brachial access. The side branch endoprosthesis was deployed and the patency of the left vertebral artery was confirmed.
I performed a series of angiograms and aortograms to evaluate the success of the procedure. I found no type 1 or 3 endoleak and excellent flow to the supra-aortic trunk vessels. There was demonstrated persistent false lumen flow and compressed true lumen in the infrarenal aorta. Therefore, a Cook Zenith dissection endovascular stent was placed.
Outcome
I saw the patient one month following the procedure and he is doing well. A CTA showed excellent results with decreased false lumen diameter, stable aortic size and well-perfused supra-aortic trunk and visceral circulation. I asked him to come back for a surveillance CTA one year later.
Analysis
Thoracic branch endoprosthesis is a novel treatment that can provide great benefit to patients with aortic dissection. In this case, I utilized it to avoid possible complications, such as wound dehiscence or lymphatic leak, in a high-risk surgical patient.
