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WSU Medical School
Wayne State University
Thoracic endovascular repair (TEVAR) is the current therapy of choice for treating type B aortic dissections. This is accomplished by covering the entry tear that is distal to the left subclavian artery. When the dissection flap extends into the visceral vessels it is common to have a type 1b endoleak into the false lumen from the visceral aortic tears. When the supra-celiac aorta is of normal caliber, then fenestration of the dissection flap proximal to the visceral vessels and sealing this area with a TEVAR stent graft eliminates the type 1 b endoleak. Fenestration also helps when there is distal ischemia from an over-pressured false lumen. Fenestration has been described using needles to cross the septum and balloons to tear open the septum. We describe a novel way of crossing the septum using electrocautery delivered through a wire tip then fenestrating the septum using electrocautery delivered over a 1 mm area of uninsulated wire to cut the septum. The use of electrocautery creates a controlled and deliberate aortic fenestration during endovascular repair of a type B dissection. This case is a 59 year old male who presented with an enlarging thoracic aneurysm secondary to a residual type B artic dissection (Figure 1). We elected to treat this with a TEVAR. A TX2 thoracic endograft (Cook Vascular, IN) was inserted into the thoracic aorta and deployed covering the entry tear (Figure 2). We crossed from the true lumen to the false lumen using a 0.014 Confienza wire (Figure 3). We snared the wire in the false lumen and pulled the wire out through the contralateral groin. Then we scraped the insulation off 1 mm segment ofa 0.014 Astato wire. This was kinked at the area of denuded insulation. We then introduced the wire into the patient and positioned the uncovered wire over the dissection septum. Using the electrocautery, we made a 3 cm cut in the septum (Figure 4). Finally, we deployed a distal TEVAR stent landing the distal segments in the fenestration giving us a distal seal (Figure 5). Post-procedure CTA showed complete exclusion of the aneurysm with no distal endoleaks. This novel technique was adopted to help treat a type B dissection.
McLaughlin, Dylan; Bendix, Scott; Lin, Judith; and Kabbani, Loay S., "A Novel Way to Fenestrate a Type B Dissection Flap Using Electrocautery" (2019). Case Reports. 118.