- Email: [email protected]
Cheese Wire Fenestration of a Chronic Juxtarenal Dissection Flap to Facilitate Proximal Neck Fixation during EVAR
Cheese Wire Fenestration of a Chronic Juxtarenal Dissection Flap to Facilitate Proximal Neck Fixation during EVAR Brant W. Ullery, Venita Chandra, Michael Dake, and Jason T. Lee, Stanford, California
Background: To describe successful endovascular repair of a complex chronic aortoiliac dissection facilitated by a unique endovascular fenestration technique at the proximal neck. Methods: A 57-year-old man presented with disabling lower extremity claudication and a remote history of medically treated type B aortic dissection. Computed tomographic angiography demonstrated a complex dissection with 7.1-cm false lumen aneurysmal dilatation and significant true lumen compression within bilateral iliac aneurysms and no suitable proximal infrarenal neck free of dissection. Results: Using intravascular ultrasound, guidewires were introduced into true and false lumens. A 9F sheath was placed on the right side, and a 20-ga Chiba needle was positioned at the level of the celiac artery and oriented toward the dissection flap. The needle was advanced to puncture the flap, and a 0.014-in wire was then snared from the true to the false lumen. Shearing of the dissection flap in the juxtarenal segment was performed using a ‘‘cheese wire’’ technique, whereby both ends of the guidewire were pulled caudally in a sawing motion down through the infrarenal neck and into the aneurysm sac. Angiography confirmed absence of residual dissection and perfusion of the visceral vessels via the true lumen. Given the newly created infrarenal neck, standard endovascular aortic repair (EVAR) was performed and antegrade and retrograde false lumen flow was obliterated from the visceral vessels. Postoperative imaging confirmed aneurysm exclusion, no endoleak, and patent bilateral common iliac arteries with resolution of claudication symptoms and normal ankle-brachial indices. Conclusions: Endovascular management of false lumen aneurysms in the setting of chronic dissection is limited by the ability of stent grafts to obtain adequate proximal or distal fixation. Endovascular fenestration of these chronic flaps facilitates generation of suitable landing zones, thereby serving as a useful adjunct to standard EVAR.
Stanford type B aortic dissections are typically managed medically with anti-impulse therapy aimed at achieving strict blood pressure control and monitoring for end-organ ischemia.
Presented at the Peripheral Vascular Surgical Society Winter Meeting, Steamboat Springs, CO, February 2014.
Complicated type B aortic dissections may involve false lumen aneurysmal dilatation and associated true lumen compression, thereby resulting in malperfusion of the viscera or lower extremities and predisposing to aortic rupture. Endovascular treatment of aortic dissections has emerged as a viable therapeutic alternative to conventional open surgical approaches.
Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA. Correspondence to: Jason T. Lee, MD, Division of Vascular Surgery, Stanford University Medical Center, 300 Pasteur Drive, H3636, Stanford, CA 94305, USA; E-mail: [email protected] Ann Vasc Surg 2015; 29: 124.e1e124.e5 http://dx.doi.org/10.1016/j.avsg.2014.07.025 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: April 14, 2014; manuscript accepted: July 27, 2014; published online: September 2, 2014 .
CASE REPORT A 57-year-old man with a history of a type A aortic dissection and proximal descending thoracic aortic aneurysm repair underwent computed tomographic angiography (CTA) after the recent onset of disabling short-distance claudication in the setting of a known chronic residual 124.e1
124.e2 Case reports
Annals of Vascular Surgery
Fig. 1. Computed tomographic angiography demonstrating complex thoracoabdominal aortoiliac dissection (A) with false lumen dilatation (B), absence of adequate
infrarenal neck for standard endovascular repair (C), and true lumen compression of bilateral iliac arteries (D).
type B aortic dissection. The imaging was notable for a complex thoracoabdominal aortoiliac dissection, which included a new 7.1-cm false lumen dilatation of the infrarenal abdominal aorta and significant true lumen compression within bilateral iliac artery aneurysms measuring 5.2 cm on the right and 4.8 cm on left (Fig. 1). The finding of false aneurysmal degeneration was not observed on imaging before 2 years. The true lumen supplied the inferior mesenteric, bilateral renal, and bilateral iliac arteries. The false lumen supplied the celiac artery, whereas the superior mesenteric artery had a shared origin from both the true and the false lumens. Aside from his claudication, the patient was otherwise asymptomatic and hemodynamically stable. Because of his significant past surgical history, which was complicated by multiple episodes of perioperative cardiac arrest, he was not deemed to be a candidate for open surgical intervention. Moreover, he was not considered an anatomically suitable candidate for standard endovascular aortic repair (EVAR) as a result of true lumen compression at the level of the infrarenal neck and a thickened septum. Our endovascular plan was therefore to create a more suitable infrarenal neck by performing an endovascular fenestration. Using intravascular ultrasound guidance (8.5F, 10 MHz, Visions PV .035 Digital IVUS Catheter; Volcano Corp, San Diego, CA), transfemoral arterial access was obtained and guidewires were introduced into the true lumen from the right femoral artery and false lumen from the left femoral artery. Initial angiography confirmed appropriate wire access into the true and false lumens (Fig. 2). A 9F, multipurpose, shaped, guide catheter was advanced into the suprarenal location from the right femoral artery, traversing through the true lumen and oriented in a perpendicular fashion toward the false lumen. Using a 21-ga Chiba needle (Cook Medical, Bloomington, IN), a single-pass perforation of the dissection flap was performed, allowing advancement
of a 0.014-in hydrophilic wire (Terumo Medical, Somerset, NJ) across the flap. Subsequent contrast injection from the right side confirmed successful entry into the false lumen. The newly created fenestration was dilated using a 4 mm balloon to facilitate transseptal advancement of a 4F Omni Flush Catheter (Angiodynamics, Latham, NY) from the true lumen side. A false lumen angiogram was then performed. Once we were confident that we had created a tract from true lumen to false lumen, we inserted an 18 mm EN Snare device (Merit Medical, South Jordan, UT) via a 7F sheath from the false lumen on the left side to capture the 0.014-in wire, thereby achieving through-and-through bifemoral guidewire access across the dissection flap. Using a ‘‘cheese wire’’ technique, gentle downward traction was applied to both the ends of the wire to shear the flap for several centimeters caudally. This maneuver was performed cautiously under fluoroscopy to ensure that intimal dissection did not extend beyond the aortic bifurcation. Angiography then confirmed the creation of a suitable infrarenal neck for EVAR with a diameter of 27 mm that was free of significant thrombus and calcification (Fig. 3). A modular bifurcated Gore Excluder aortic stent graft (W.L. Gore and Associates, Flagstaff, AZ) measuring 35 mm 14.5 mm 16 cm was placed from the right femoral artery and positioned immediately caudal to the left renal artery. A 16 14.5 mm2 contralateral limb was placed from the left femoral artery. Two iliac extension pieces were needed in the right iliac artery distribution to achieve an adequate seal, and this mandated coverage of the right hypogastric artery. The left hypogastric artery was preserved. Additional placement of a covered stent outside the treatment zone was ultimately required to resolve endoleaks secondary to fenestrations in the proximal bilateral external iliac arteries (10 mm 5-cm VIABAHN stent graft [W.L. Gore and Associates] in right external iliac and 9 38 mm2 iCAST stent graft
Vol. 29, No. 1, January 2015
Fig. 2. (A) Initial aortogram demonstrating true lumen entry via right side. False lumen wire access is achieved via left side. (B) After successful flap puncture with the use of a 21-ga Chiba needle, a wire is advanced across the dissection flap from the true lumen side. (C) Snare
Case reports 124.e3
capture of a 0.014-in wire is performed from the false lumen on the left side. (D) Through-and-through bifemoral wire access is obtained. Cheese wire fenestration is then performed by putting gentle downward traction on both ends of the wire.
Fig. 3. (A) After cheese wire fenestration, a new infrarenal aortic neck is created, which is suitable for endovascular repair. (B) Standard endovascular aortic repair is then performed.
[Atrium Medical, Hudson, NH] in the left external iliac artery). Completion angiography confirmed that antegrade and retrograde false lumen flow was obliterated from the visceral vessels and no evidence of endoleak (Fig. 4). The patient had an uneventful postoperative course and was discharged on the fourth postoperative
day. At 8-month follow-up, he no longer complains of claudication and has normal ankle-brachial indices. Postoperative CTA confirmed aneurysm exclusion with aneurysmal sac regression, no endoleak, adequate visceral perfusion, and patent bilateral common iliac arteries.
124.e4 Case reports
Fig. 4. Postoperative computed tomographic angiography demonstrating no endoleak.
DISCUSSION EVAR is frequently used as the initial endovascular strategy in complicated type B aortic dissections to exclude false lumen flow and re-expand the true lumen via the coverage of proximal entry sites. Additional endovascular strategies to decompress the false lumen and augment true lumen perfusion have centered on percutaneous abdominal aortic fenestration techniques. First described in 1990,1 endovascular fenestration has since evolved to include the utilization of multiple different devices, ranging from large-bore, transjugular, intrahepatic, portosystemic, shunt needles to the newer, needle-based, re-entry catheters. The cheese wire maneuver represents an additional modification to endovascular fenestration.2e6
Annals of Vascular Surgery
Wuest et al.5 reported the first endovascular flap fenestration in the setting of an acute type B dissection using the OUTBACK Re-entry Catheter (Cordis, Miami, FL). Kos et al.2 have since described their experience with 4 male patients with acute complicated type B aortic dissections treated in the same manner. The authors were able to successfully perform membrane puncture using the re-entry device, subsequent guidewire passage, guidewire snaring, and the ‘‘cheese wire’’ maneuver in all cases. With only 1 exception, all reports to date have described the cheese wire maneuver in the context of acute aortic dissection. Needle-based re-entry devices are designed for a thin, fragile, dissection flap that commonly accompanies an acute dissection; however, such delicate devices may prove to be of insufficient caliber to penetrate the thicker septa seen in chronic dissection flaps. Tashiro et al.6 recently described the only other use of the cheese wire maneuver in the setting of a chronic aortic dissection flap to facilitate endovascular repair of a contained aneurysm rupture. Their report included the novel use of a 16-ga Colapinto needle (Cook Medical) opposing a contrast-filled Coda balloon (Cook Medical) placed from the false lumen side to provide sufficient rigidity to penetrate the flap. The authors also noted the additional benefit of instant verification of a successful puncture with this technique when visualizing contrast leaking from the balloon. In our case, puncture orientation was guided by a combination of preoperative imaging and fluoroscopy, and a Chiba needle provided adequate force to puncture the dissection flap. The challenge associated with endovascular repair of the aortoiliac false lumen aneurysm in our case was based primarily on the lack of adequate infrarenal aortic neck for the standard Gore device. Moreover, our therapeutic dilemma was further complicated by the perceived inability to obtain a proximal seal as a result of the opposition of the chronic dissection flap against the radial force exerted by the stent graft. As such, cheese wire fenestration at the level of the juxtarenal aorta was instrumental in the creation of an adequate infrarenal neck for standard EVAR. Antegrade and retrograde false lumen flow was obliterated from the visceral vessels, and expansion of the iliac artery true lumens was achieved after deployment of the aortic stent grafts. The distal extent of the dissections was obliterated with the use of covered stents in the bilateral external iliac arteries. In our practice, patients with aortic dissections are generally considered candidates for endovascular septotomy if they need creation of a more suitable aneurysm neck for EVAR or if they would
Vol. 29, No. 1, January 2015
benefit from mixing of true and false lumen flow for the treatment of end-organ ischemia. Although chronic dissections may portend a lower success rate of endovascular septotomy owing to thicker and more rigid septa, we do not consider the chronicity of the dissection to be a major factor in our patient selection. We believe routine stent-graft placement after the cheese wire technique ameliorates the risk of several potential complications associated with this endovascular strategy, including perforation, trap door phenomenon (when the septum closes on a branch vessel and causes a dynamic obstruction), and obstruction due to a large piece of septum getting pulled down into the aortic bifurcation. In conclusion, endovascular management of false lumen aneurysms in the setting of chronic dissection is limited by the ability of stent grafts to obtain adequate proximal or distal fixation. Endovascular fenestration of these chronic flaps facilitates generation of suitable landing zones, thereby serving as a useful adjunct to standard
Case reports 124.e5
EVAR in the treatment of complex aortoiliac aneurysms and dissections. REFERENCES 1. Williams DM, Brothers TE, Messina LM. Relief of mesenteric ischemia in type III aortic dissection with percutaneous fenestration of the aortic septum. Radiology 1990;174:450e2. 2. Kos S, Gurke L, Jacob AL. A novel fenestration technique for abdominal aortic dissection membranes using a combination of a needle re-entry catheter and the ‘‘cheese-wire’’ technique. Cardiovasc Intervent Radiol 2011;34:1296e302. 3. Watkinson AF. A novel ‘‘cheese wire’’ technique for stent positioning following difficult iliac artery subintimal dissection and aortic re-entry. Cardiovasc Intervent Radiol 2009;32:781e4. 4. Jacobs DL, Motaganahalli RL, Cox DE, et al. True lumen re-entry devices facilitate subintimal angioplasty and stenting of total chronic occlusions: initial report. J Vasc Surg 2006;43: 1291e6. 5. Wuest W, Goltz J, Ritter C, et al. Fenestration of aortic dissection using a fluoroscopy-based needle re-entry catheter system. Cardiovasc Intervent Radiol 2009;34:S44e7. 6. Tashiro J, Baqai A, Goldstein LJ, et al. ‘‘Cheese wire’’ fenestration of a chronic aortic dissection flap for endovascular repair of a contained aneurysm rupture. J Vasc Surg 2013;60:497e9.
Background: To describe successful endovascular repair of a complex chronic aortoiliac dissection facilitated by a unique endovascular fenestration technique at the proximal neck. Methods: A 57-year-old man presented with disabling lower extremity claudication and a remote history of medically treated type B aortic dissection. Computed tomographic angiography demonstrated a complex dissection with 7.1-cm false lumen aneurysmal dilatation and significant true lumen compression within bilateral iliac aneurysms and no suitable proximal infrarenal neck free of dissection. Results: Using intravascular ultrasound, guidewires were introduced into true and false lumens. A 9F sheath was placed on the right side, and a 20-ga Chiba needle was positioned at the level of the celiac artery and oriented toward the dissection flap. The needle was advanced to puncture the flap, and a 0.014-in wire was then snared from the true to the false lumen. Shearing of the dissection flap in the juxtarenal segment was performed using a ‘‘cheese wire’’ technique, whereby both ends of the guidewire were pulled caudally in a sawing motion down through the infrarenal neck and into the aneurysm sac. Angiography confirmed absence of residual dissection and perfusion of the visceral vessels via the true lumen. Given the newly created infrarenal neck, standard endovascular aortic repair (EVAR) was performed and antegrade and retrograde false lumen flow was obliterated from the visceral vessels. Postoperative imaging confirmed aneurysm exclusion, no endoleak, and patent bilateral common iliac arteries with resolution of claudication symptoms and normal ankle-brachial indices. Conclusions: Endovascular management of false lumen aneurysms in the setting of chronic dissection is limited by the ability of stent grafts to obtain adequate proximal or distal fixation. Endovascular fenestration of these chronic flaps facilitates generation of suitable landing zones, thereby serving as a useful adjunct to standard EVAR.
Stanford type B aortic dissections are typically managed medically with anti-impulse therapy aimed at achieving strict blood pressure control and monitoring for end-organ ischemia.
Presented at the Peripheral Vascular Surgical Society Winter Meeting, Steamboat Springs, CO, February 2014.
Complicated type B aortic dissections may involve false lumen aneurysmal dilatation and associated true lumen compression, thereby resulting in malperfusion of the viscera or lower extremities and predisposing to aortic rupture. Endovascular treatment of aortic dissections has emerged as a viable therapeutic alternative to conventional open surgical approaches.
Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA. Correspondence to: Jason T. Lee, MD, Division of Vascular Surgery, Stanford University Medical Center, 300 Pasteur Drive, H3636, Stanford, CA 94305, USA; E-mail: [email protected] Ann Vasc Surg 2015; 29: 124.e1e124.e5 http://dx.doi.org/10.1016/j.avsg.2014.07.025 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: April 14, 2014; manuscript accepted: July 27, 2014; published online: September 2, 2014 .
CASE REPORT A 57-year-old man with a history of a type A aortic dissection and proximal descending thoracic aortic aneurysm repair underwent computed tomographic angiography (CTA) after the recent onset of disabling short-distance claudication in the setting of a known chronic residual 124.e1
124.e2 Case reports
Annals of Vascular Surgery
Fig. 1. Computed tomographic angiography demonstrating complex thoracoabdominal aortoiliac dissection (A) with false lumen dilatation (B), absence of adequate
infrarenal neck for standard endovascular repair (C), and true lumen compression of bilateral iliac arteries (D).
type B aortic dissection. The imaging was notable for a complex thoracoabdominal aortoiliac dissection, which included a new 7.1-cm false lumen dilatation of the infrarenal abdominal aorta and significant true lumen compression within bilateral iliac artery aneurysms measuring 5.2 cm on the right and 4.8 cm on left (Fig. 1). The finding of false aneurysmal degeneration was not observed on imaging before 2 years. The true lumen supplied the inferior mesenteric, bilateral renal, and bilateral iliac arteries. The false lumen supplied the celiac artery, whereas the superior mesenteric artery had a shared origin from both the true and the false lumens. Aside from his claudication, the patient was otherwise asymptomatic and hemodynamically stable. Because of his significant past surgical history, which was complicated by multiple episodes of perioperative cardiac arrest, he was not deemed to be a candidate for open surgical intervention. Moreover, he was not considered an anatomically suitable candidate for standard endovascular aortic repair (EVAR) as a result of true lumen compression at the level of the infrarenal neck and a thickened septum. Our endovascular plan was therefore to create a more suitable infrarenal neck by performing an endovascular fenestration. Using intravascular ultrasound guidance (8.5F, 10 MHz, Visions PV .035 Digital IVUS Catheter; Volcano Corp, San Diego, CA), transfemoral arterial access was obtained and guidewires were introduced into the true lumen from the right femoral artery and false lumen from the left femoral artery. Initial angiography confirmed appropriate wire access into the true and false lumens (Fig. 2). A 9F, multipurpose, shaped, guide catheter was advanced into the suprarenal location from the right femoral artery, traversing through the true lumen and oriented in a perpendicular fashion toward the false lumen. Using a 21-ga Chiba needle (Cook Medical, Bloomington, IN), a single-pass perforation of the dissection flap was performed, allowing advancement
of a 0.014-in hydrophilic wire (Terumo Medical, Somerset, NJ) across the flap. Subsequent contrast injection from the right side confirmed successful entry into the false lumen. The newly created fenestration was dilated using a 4 mm balloon to facilitate transseptal advancement of a 4F Omni Flush Catheter (Angiodynamics, Latham, NY) from the true lumen side. A false lumen angiogram was then performed. Once we were confident that we had created a tract from true lumen to false lumen, we inserted an 18 mm EN Snare device (Merit Medical, South Jordan, UT) via a 7F sheath from the false lumen on the left side to capture the 0.014-in wire, thereby achieving through-and-through bifemoral guidewire access across the dissection flap. Using a ‘‘cheese wire’’ technique, gentle downward traction was applied to both the ends of the wire to shear the flap for several centimeters caudally. This maneuver was performed cautiously under fluoroscopy to ensure that intimal dissection did not extend beyond the aortic bifurcation. Angiography then confirmed the creation of a suitable infrarenal neck for EVAR with a diameter of 27 mm that was free of significant thrombus and calcification (Fig. 3). A modular bifurcated Gore Excluder aortic stent graft (W.L. Gore and Associates, Flagstaff, AZ) measuring 35 mm 14.5 mm 16 cm was placed from the right femoral artery and positioned immediately caudal to the left renal artery. A 16 14.5 mm2 contralateral limb was placed from the left femoral artery. Two iliac extension pieces were needed in the right iliac artery distribution to achieve an adequate seal, and this mandated coverage of the right hypogastric artery. The left hypogastric artery was preserved. Additional placement of a covered stent outside the treatment zone was ultimately required to resolve endoleaks secondary to fenestrations in the proximal bilateral external iliac arteries (10 mm 5-cm VIABAHN stent graft [W.L. Gore and Associates] in right external iliac and 9 38 mm2 iCAST stent graft
Vol. 29, No. 1, January 2015
Fig. 2. (A) Initial aortogram demonstrating true lumen entry via right side. False lumen wire access is achieved via left side. (B) After successful flap puncture with the use of a 21-ga Chiba needle, a wire is advanced across the dissection flap from the true lumen side. (C) Snare
Case reports 124.e3
capture of a 0.014-in wire is performed from the false lumen on the left side. (D) Through-and-through bifemoral wire access is obtained. Cheese wire fenestration is then performed by putting gentle downward traction on both ends of the wire.
Fig. 3. (A) After cheese wire fenestration, a new infrarenal aortic neck is created, which is suitable for endovascular repair. (B) Standard endovascular aortic repair is then performed.
[Atrium Medical, Hudson, NH] in the left external iliac artery). Completion angiography confirmed that antegrade and retrograde false lumen flow was obliterated from the visceral vessels and no evidence of endoleak (Fig. 4). The patient had an uneventful postoperative course and was discharged on the fourth postoperative
day. At 8-month follow-up, he no longer complains of claudication and has normal ankle-brachial indices. Postoperative CTA confirmed aneurysm exclusion with aneurysmal sac regression, no endoleak, adequate visceral perfusion, and patent bilateral common iliac arteries.
124.e4 Case reports
Fig. 4. Postoperative computed tomographic angiography demonstrating no endoleak.
DISCUSSION EVAR is frequently used as the initial endovascular strategy in complicated type B aortic dissections to exclude false lumen flow and re-expand the true lumen via the coverage of proximal entry sites. Additional endovascular strategies to decompress the false lumen and augment true lumen perfusion have centered on percutaneous abdominal aortic fenestration techniques. First described in 1990,1 endovascular fenestration has since evolved to include the utilization of multiple different devices, ranging from large-bore, transjugular, intrahepatic, portosystemic, shunt needles to the newer, needle-based, re-entry catheters. The cheese wire maneuver represents an additional modification to endovascular fenestration.2e6
Annals of Vascular Surgery
Wuest et al.5 reported the first endovascular flap fenestration in the setting of an acute type B dissection using the OUTBACK Re-entry Catheter (Cordis, Miami, FL). Kos et al.2 have since described their experience with 4 male patients with acute complicated type B aortic dissections treated in the same manner. The authors were able to successfully perform membrane puncture using the re-entry device, subsequent guidewire passage, guidewire snaring, and the ‘‘cheese wire’’ maneuver in all cases. With only 1 exception, all reports to date have described the cheese wire maneuver in the context of acute aortic dissection. Needle-based re-entry devices are designed for a thin, fragile, dissection flap that commonly accompanies an acute dissection; however, such delicate devices may prove to be of insufficient caliber to penetrate the thicker septa seen in chronic dissection flaps. Tashiro et al.6 recently described the only other use of the cheese wire maneuver in the setting of a chronic aortic dissection flap to facilitate endovascular repair of a contained aneurysm rupture. Their report included the novel use of a 16-ga Colapinto needle (Cook Medical) opposing a contrast-filled Coda balloon (Cook Medical) placed from the false lumen side to provide sufficient rigidity to penetrate the flap. The authors also noted the additional benefit of instant verification of a successful puncture with this technique when visualizing contrast leaking from the balloon. In our case, puncture orientation was guided by a combination of preoperative imaging and fluoroscopy, and a Chiba needle provided adequate force to puncture the dissection flap. The challenge associated with endovascular repair of the aortoiliac false lumen aneurysm in our case was based primarily on the lack of adequate infrarenal aortic neck for the standard Gore device. Moreover, our therapeutic dilemma was further complicated by the perceived inability to obtain a proximal seal as a result of the opposition of the chronic dissection flap against the radial force exerted by the stent graft. As such, cheese wire fenestration at the level of the juxtarenal aorta was instrumental in the creation of an adequate infrarenal neck for standard EVAR. Antegrade and retrograde false lumen flow was obliterated from the visceral vessels, and expansion of the iliac artery true lumens was achieved after deployment of the aortic stent grafts. The distal extent of the dissections was obliterated with the use of covered stents in the bilateral external iliac arteries. In our practice, patients with aortic dissections are generally considered candidates for endovascular septotomy if they need creation of a more suitable aneurysm neck for EVAR or if they would
Vol. 29, No. 1, January 2015
benefit from mixing of true and false lumen flow for the treatment of end-organ ischemia. Although chronic dissections may portend a lower success rate of endovascular septotomy owing to thicker and more rigid septa, we do not consider the chronicity of the dissection to be a major factor in our patient selection. We believe routine stent-graft placement after the cheese wire technique ameliorates the risk of several potential complications associated with this endovascular strategy, including perforation, trap door phenomenon (when the septum closes on a branch vessel and causes a dynamic obstruction), and obstruction due to a large piece of septum getting pulled down into the aortic bifurcation. In conclusion, endovascular management of false lumen aneurysms in the setting of chronic dissection is limited by the ability of stent grafts to obtain adequate proximal or distal fixation. Endovascular fenestration of these chronic flaps facilitates generation of suitable landing zones, thereby serving as a useful adjunct to standard
Case reports 124.e5
EVAR in the treatment of complex aortoiliac aneurysms and dissections. REFERENCES 1. Williams DM, Brothers TE, Messina LM. Relief of mesenteric ischemia in type III aortic dissection with percutaneous fenestration of the aortic septum. Radiology 1990;174:450e2. 2. Kos S, Gurke L, Jacob AL. A novel fenestration technique for abdominal aortic dissection membranes using a combination of a needle re-entry catheter and the ‘‘cheese-wire’’ technique. Cardiovasc Intervent Radiol 2011;34:1296e302. 3. Watkinson AF. A novel ‘‘cheese wire’’ technique for stent positioning following difficult iliac artery subintimal dissection and aortic re-entry. Cardiovasc Intervent Radiol 2009;32:781e4. 4. Jacobs DL, Motaganahalli RL, Cox DE, et al. True lumen re-entry devices facilitate subintimal angioplasty and stenting of total chronic occlusions: initial report. J Vasc Surg 2006;43: 1291e6. 5. Wuest W, Goltz J, Ritter C, et al. Fenestration of aortic dissection using a fluoroscopy-based needle re-entry catheter system. Cardiovasc Intervent Radiol 2009;34:S44e7. 6. Tashiro J, Baqai A, Goldstein LJ, et al. ‘‘Cheese wire’’ fenestration of a chronic aortic dissection flap for endovascular repair of a contained aneurysm rupture. J Vasc Surg 2013;60:497e9.