A Novel Way to Fenestrate a Type B Dissection Flap Using Endovascular Electrocautery
Kabbani L, Judith Lin ME, McLaughlin D, and Bendix S. A Novel Way to Fenestrate a Type B Dissection Flap Using Endovascular Electrocautery. J Vasc Surg 2019; 70(3):e71-e72.
J Vasc Surg
Thoracic endovascular aortic repair (TEVAR) is the current therapy of choice for 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 IB endoleak into the false lumen from the visceral aortic tears. When the supraceliac aorta is of normal caliber, fenestration of the dissection flap proximal to the visceral vessels and sealing of this area with a TEVAR stent graft eliminate the type IB endoleak. Fenestration also helps when there is distal ischemia from an overpressured 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. Case report: A 59-year-old man presented with an enlarging thoracic aneurysm secondary to a residual type B artic dissection. We elected to treat this with TEVAR. A TX2 thoracic endograft (Cook Vascular, Bloomington, Ind) was inserted into the thoracic aorta and deployed, covering the entry tear. We crossed from the true lumen to the false lumen using a 0.014-inch Confianza wire (Asahi Intecc Co, Ltd, Tokyo, Japan; Fig 1). We snared the wire in the false lumen and pulled the wire out through the contralateral groin. We then scraped the insulation off a 1-mm segment of a 0.014-inch Astato wire (Asahi Intecc Co, Ltd). 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 (Fig 2). Finally, we deployed a distal TEVAR stent, landing the distal segments in the fenestration, giving us a distal seal. Postprocedure computed tomography angiography showed complete exclusion of the aneurysm with no distal endoleaks. This novel technique was adopted to help treat a type B dissection. [Figure presented] [Figure presented]