Aortic Fenestration: A Why, When, and How-to Guide

Abstract

The management of aortic dissection can be challenging. Most cases of acute type A dissection are managed surgically. Most cases of acute type B dissection are managed medically, although open surgery or stent-graft placement is sometimes performed. Patients with type B or surgically treated type A dissection may develop vascular complications such as mesenteric or peripheral ischemia, which cannot be managed medically. Aortic fenestration is a method for decompressing the hypertensive false lumen by creating a hole in the distal part of the dissection flap. This procedure allows outflow from the false lumen, thereby reducing intraluminal pressure, relieving branch vessel obstruction, and reducing the risk of extension of the dissection. Urgent revascularization is required to correct mesenteric and renal ischemia and to reestablish distal perfusion if there is resting ischemia. Few operators will acquire extensive personal experience with percutaneous aortic fenestration. Nevertheless, with a good understanding of the pathologic condition, careful demonstration of the anatomy, good technical skills, and access to high-quality imaging (including intravascular ultrasonography) and the requisite equipment, most interventional radiologists skilled in arterial interventions should be capable of performing this procedure. However, because further interventions are frequently required, the radiologist needs to maintain contact with the patient to ensure timely treatment of any subsequent complications.

Acute Aortic Emergencies—Part 2 Aortic Dissections

“…Risk factors (see Table 1) relate to inherited and acquired weakening of the aortic media and intimal disease (Bonser et al, 2011;Braverman, 2010;Golledge & Eagle, 2008;Green & Kron, 2003;Hartnell & Gates, 2005;Hiratzka et al, 2010;Karthikesalingam, Holt, Hinchliffe, Thompson, & Loftus, 2010;Khoynezhad & Prestis, 2006;Landman & Torbati, 2012;O'Donnell et al, 2011;Secemsky, Lange, Waters, Goldsshlager, & Hsue, 2011;Stout, Scott, Stokes, & Panneton, 2010;Tilney, 2010;Upadhye & Schiff, 2012;Westover & Nakonezny, 2010;Wittels, 2011). Risk factors can be divided into two mechanisms:…”

“…Other presentations reported in the literature include heart failure, heart block, syncope, focal neurological complaints such as extremity weakness, numbness, and hemiparesis, or transient global amnesia (Braverman, 2010;Liu et al, 2010;Scaglione et al, 2008;Upadhye & Schiff, 2012;Wittels, 2011). Table 4 lists complications of AD (Hartnell & Gates, 2005). Malperfusion to the heart, arms, head, spinal cord, gut, kidneys, and legs occurs from dissection extending into those re- spective arteries or the false lumen occluding perfusion (Bonser et al, 2011).…”

“…A laparotomy to assess for areas of mesenteric infarction may be required with persistent pain or metabolic acidosis. Prolonged peripheral ischemia to an extremity may require an immediate fasciotomy to prevent compartment syndrome (Hartnell & Gates, 2005). Visceral artery involvement is predictive of poor outcome and proves fatal in up to one third of patients due to the extent of vascular involvement and the development of multiple-organ failure (Hartnell & Gates, 2005).…”

Malperfusion bei Aortendissektion

“…Eine lange Extremitätenischämie mit verzögerter Reperfusion kann eine schnelle Fasziotomie erfordern, um ein entstandenes Kompartmentsyndrom zu entlasten ( [33]; . Abb.…”

Malperfusion Syndrome in Type B Aortic Dissection: Role of the Endovascular Procedures

“…Persistent pain or metabolic acidosis may require laparotomy to assess for areas of mesenteric infarction. Prolonged peripheral limb ischemia may require immediate fasciotomy to prevent compartment syndrome (23). Unfortunately, these procedures can be complicated by suboptimal mid-term outcomes, in relation with post-procedural morbidity or mortality.…”