In 2010, a 69-year-old patient was treated in another hospital with a mitral valve replacement, complicated by a Stanford type-A dissection. In January 2019 he presented with an enlarging infrarenal post-dissection aneurysm with a maximum diameter of 81 mm. In 2010 this diameter was 52 mm.
Contrast-enhanced computed tomography (CTA) scanning showed a post-dissection infrarenal aneurysm without filling through the proximal entry tear. The original dissection originated from the aortic arch to the abdominal aorta and extended to the right common iliac artery (CIA) (Fig. 2a and b). Diameters at the thoracic level were below the threshold for intervention. The celiac trunk and superior mesenteric artery derived from the true lumen, while the left renal artery derived from the false lumen and was occluded. There was filling of the false lumen of the aneurysm through the inferior mesenteric artery (IMA) and the right external iliac artery (Fig. 2a). The maximum diameter of the aneurysm was 81 mm, with a true lumen diameter of 57 mm (Fig. 2c).
After ample consideration and informed consent, patient was scheduled for embolization of the IMA and filling of the false lumen, using IMPEDE-FX embolization plugs. Patient was operated under general anesthesia and antibiotic prophylaxis. After placement of a 5-F sheath a blowback angiography was performed (Fig. 3a). Subsequently, the false lumen was cannulated. Angiography showed the false lumen and the IMA (Fig. 3b). Subsequently a 5-F sheath was advanced into the IMA, and it was embolized using a 5 × 80 mm Interlock-18 microcoil (Boston Scientific, Marlborough, MA) to prevent distal migration of the IMPEDE-FX Plug, just before its first bifurcation and proximal of Riolan, to guarantee collateral flow. Then an IMPEDE-FX-12 Embolization Plug was placed in the orifice of the IMA followed by 6 other IMPEDE-FX-12 Embolization Plugs, that filled the entire false lumen (Fig. 3d).
Afterwards, the true lumen was cannulated and, in order to cover the entry in the iliac artery, a 11mmx39 balloon-expandable covered stent (GORE®VIABAHN®VBX Balloon Expandable Endoprosthesis, W.L.Gore and associates, Flagstaff, AZ) was placed in external iliac artery. Completion angiography showed a fully excluded false lumen with patent flow through the true lumen. The most distal plug, however, seemed to have moved distally, indicating that the CIA entry was not fully covered. Therefore, the balloon-expandable covered stent was extended distally to the level of the deep inferior epigastric artery with a good result. The access site was closed using an Angio-Seal (Terumo Interventional Systems, Somerset, NJ) vascular closure device. The post-procedural course was uneventful and patient was discharged at the first postoperative day.
At one-month a CTA showed a fully thrombosed false lumen. The diameter of the aneurysm was 77 mm (Fig. 2d). At 8 and 15 months another CTA confirmed complete and persistent thrombosis of the false lumen. The total diameter of the false lumen remained stable (Fig. 2e and f). Furthermore, remodeling of the true lumen was evident. The shape of the true lumen had changed as the thrombus load at the left lateral side was increased (Fig. 2). The maximum diameter of the true lumen decreased from 56 mm to 52 mm. The volume of the true lumen showed a similar decrease, with a preoperative volume of 102.4 cm3, and a volume of 109.2 cm3 and 87.5 cm3 at 1 and 8 months, respectively.