Endovascular “Intimal Flap Septostomy” for Safe Landing of a Stent Graft in an Anastomotic Pseudoaneurysm of Chronic Type B Aortic Dissection☆

Objective/Background The purpose of this report is to demonstrate a novel endovascular technique for gaining and producing the maximal landing zone for a thoracic stent graft in a patient with a chronic type B aortic dissection. Methods The patient was a 64 year old man with chronic type B aortic dissection. He had developed acute type B aortic dissection and undergone descending thoracic replacement (Zone 2-Th10) 12 years earlier. During follow-up, he developed an anastomotic false aneurysm distally. In the initial operation, the distal anastomosis was performed with fenestration of the dissecting membrane. Computed tomography showed a pseudoaneurysm of 54 mm that was positioned 9 cm proximal to the coeliac artery. The landing zone was < 20 mm in the fenestrated area. At surgery, the true and false lumens were each cannulated from the femoral artery, and a pull through form was made just above the fenestrated flap. After the wire exchange, a 4 mm cutting balloon was positioned on the bottom of the flap, and the flap was gently sawed about 3.5 cm. Results After stent graft placement no endoleak was observed. The patient was discharged without any complications. Conclusion This technique was effective in producing a sufficient landing zone for endovascular aortic repair in a patient with an anastomotic pseudoaneurysm of chronic type B aortic dissection.