Transapical Wire–Assisted Endovascular Repair of Thoracic Aortic Dissection

Abstract

Purpose

To describe a technique for transapical wire–assisted endograft deployment under rapid ventricular pacing for a type B dissection involving the proximal left subclavian artery and extending to the aortic bifurcation.

Case Report

A 58-year-old man presented with a symptomatic thoracic aneurysm as a complication of a chronic type B dissection, with a short proximal neck in zone 1. After arch vessel debranching, the patient underwent endoluminal repair with deployment of a closed web, tapered Valiant thoracic endograft over a through-and-through wire from the left groin to the apex of the left ventricle, using rapid ventricular pacing to reduce cardiac output. The remaining dissected aorta was covered with a second Valiant endograft down to the distal third of the descending thoracic aorta and bare Z stents down to the aortic bifurcation to re-expand the true lumen. A freeflow Valiant endograft was deployed as a proximal extension to treat a proximal type I endoleak. The recovery was complicated by retrograde type A aortic dissection, considered secondary to the bare stent. The complication was repaired surgically; postoperative computed tomography after recovery was unremarkable.

Conclusion

Transapical wire–assisted deployment with rapid ventricular pacing is feasible and may provide improved stability for stenting within the aortic arch. The use of a stent-graft with a proximal bare stent is associated with a higher risk of retrograde extension of the dissection and warrants lifelong imaging follow-up.