case_images: PMC10798097_01
case_images: Contrast-enhanced computed tomography prior fenestrating the aortic dissection membrane showing a narrow true lumen and take-off of side branches from the false lumen.
case_images: 10.1177_2050313X231225867-fig1.jpg
case_images: PMC10798097_01_10.1177_2050313X231225867-fig1.jpg
case_images: fig1-2050313X231225867
case_images: Over the last 6 months, there was a substantial increase in aortic diameter (>10 mm) (Figures 1 and 2).
case_images: Axial contrast-enhanced CT scan showing the situation prior surgery. (A) Overall diameter measuring 62 mm at the level of the suprarenal aorta. This image reveals the narrow true lumen and the patent false lumen. (B) Offspring of the left renal artery from the false lumen.
case_images: 10.1177_2050313X231225867-fig2.jpg
case_images: PMC10798097_01_10.1177_2050313X231225867-fig2.jpg
case_images: fig2-2050313X231225867
case_images: Over the last 6 months, there was a substantial increase in aortic diameter (>10 mm) (Figures 1 and 2).
case_images: Schematic diagram of the procedure. Snaring under direct vision (a) and electrocautery fenestration of the aortic dissection membrane during circulatory arrest down to the mid-descending aorta (b). After aortic arch replacement with the FET technique, completion of electro-aortic slicing down to aortic bifurcation and implanting a thoracic endograft proximal to the celiac trunk (c). This hybrid approach was the first step in the complete aortic repair and was premising for subsequent fenestrated EVAR.
case_images: 10.1177_2050313X231225867-fig3.jpg
case_images: PMC10798097_01_10.1177_2050313X231225867-fig3.jpg
case_images: fig3-2050313X231225867
case_images: An Astato Wire (Asahi Intecc, USA) was advanced through the catheter within the false lumen and inserted into the catheter within the true lumen under direct vision during (Figure 3(a)). Astato Wire was insulated in a microcatheter (Piggyback Wire Convertor, Teleflex, Wayne, PA, USA) to confine the electrical current to the tip and electrified using a radiofrequency generator (ForceFx Valley Lab, Minneapolis, MN, USA) to fenestrate the dissection membrane. As a first step, this was done under direct vision and angioscopy guidance during circulatory arrest down to the level of the mid-descending aorta (Figures 3(b) and 4). TEVAR ending just proximal to the celiac trunk (Figure 3(c)). This way we created a perfect proximal landing zone for subsequent endovascular repair which was revealed in the postoperative CT scan.
case_images: Final result after complete aortic repair.
case_images: 10.1177_2050313X231225867-fig5.jpg
case_images: PMC10798097_01_10.1177_2050313X231225867-fig5.jpg
case_images: fig5-2050313X231225867
case_images: Final imaging showed a satisfactory result with stent coverage of the entire descending and abdominal aorta and perfusion of all side branches (Figure 5).