theodoros kratimenos, md · descending thoracic aorta enlargement - first ct 35 mm, now 42-43 mm 3....

CLINICAL CASE OF SUBACUTE TYPE B DISSECTION TREATED BY TEVAR

THEODOROS KRATIMENOS, MD

INTERVENTIONAL RADIOLOGIST, CONSULTANT

EVAGGELISMOS GENERAL HOSPITAL OF ATHENS, GREECE

7- 9

2

▪ Male 47 years old,

▪ Tobacco smoker (20cig/day),

▪ hypertension(160/100mm ) not treated medically,

▪ He was admitted to another hospital with symptoms of Acute thoracic pain,

▪ After the initial clinical and laboratory investigation he performed a CT angiography which revealed:

▪ Type b dissection,

▪ He was treated with proper medical therapy and kept under surveillance,

▪ Despite the medical therapy patient was complaining for vague thoracic pain,

▪ A second CT scan was performed 2 weeks later and patient was transferred to our department.

Patient demographics, history and co-morbiditiesCLINICAL CASE

(Type b dissection)

3

PRE OP CT15 days F-up CTA reveals:

1. FL enlargement- ( first CT <13mm , now 17-26mm)

2. Descending thoracic aorta enlargement - first CT 35 mm, now 42-43 mm

3. Dissection of the descending thoracic and abdominal aorta going all the way down until the iliacs

4. Celiac trunk, SMA and Lt Renal A. originate from TL

5. Rt Renal A. is dissected but originates mainly from the TL

6. TL is compressed, FL with diameter 17-26mm,

7. Dissection starts just after the LSA orifice

CLINICAL CASE - TYPE B DISSECTION - SUBACUTE PHASECLINICAL CASE

(Type b dissection)

4

-24

SIZING & PLANNING Planning notes:

▪If we cover LSA the prox. landing zone’s length will be 25mm

▪Need to cover just after LCCA till the Celiac Trunk (total length 257mm),

▪Need for 2 stent grafts,

▪As it is a type b dissection case we decided to use Coveredseal grafts

▪A straight graft proximally and a tapered graft distally

▪Right femoral artery access looks better

5

-24

COVEREDSEAL

PROX

DISTAL

6 UC201912409EE @Medtronic 2019. All rights reserved.

▪ Right Femoral cut-down

▪ A pigtail 5Fr catheter was placed in ascending aorta for angiography through Left femoral artery access

▪ Interventional Radiolgy Unit : GE Innova 4000 Angiographic system

▪ Guide wires: terumo hydrophilic guidewire, Lunderquist extrastiff guidewire

▪ Catheters: metric pigtail 5f, vertebral 5f

▪ Stent grafts: 1 straight covered-seal Navion thoracic stent graft proximally (34-34 x 182)mm and

1 tapered covered-seal Navion thoracic stent graft distally, (37-31 x 207)mm

▪HOW DID WE TREAT THE CASECLINICAL CASE

(Type b dissection)

7

1ST GRAFT IMPLANTATION-DEPLOYMENTCLINICAL CASE

Type b dissection

8

1ST GRAFT IMPLANTATION-DEPLOYMENT-POST IMPLANTATION ANGIOGRAMCLINICAL CASE

Type b dissection

9

2ND GRAFT POSITIONING AND DEPLOYMENTCLINICAL CASE

Type b dissection

10

1ST POST TEVAR F-UP CT SCAN (45 DAYS POST OP.)

CLINICAL CASE (Type b dissection)

11

6 MONTHS POST TEVAR FOLLOW-UP CT SCANCLINICAL CASE

(Type b dissection)

Radiologic predictors.

1. a maximum aortic diameter of >40 mm in the acute phase

2. FL diameter of >22 mm in the upper thoracic descending aorta on the initial CT imaging ( independent predictor )

3. Elliptical configuration of the TL in combination with a circular formation of the FL

4. Partially thrombosed FL

5. The presence of only one patent entry tear

6. Primary entry tear>10 mm

Combining these predictors may be essential to identify patients with uncomplicated type B AD at higher risk for aortic enlargement and rupture during follow-up.

1884

1934

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