Emergency Endovascular Exclusion of False Lumen Rupture after Frozen Elephant Trunk Procedure in Type A Aortic Dissection: A Case Report

Objectives: Thoracoabdominal aortic false lumen rupture is a challenging and catastrophic problem after aortic arch surgery with 100% mortality if untreated and high mortality with open surgery. The objectives were to describe endovascular emergency approaches for occlusion of false lumen rupture after hybrid arch replacement. Methods: First Case: An 82-year-old female patient underwent repair for type A aortic dissection (TAAD) with E-VITA open plus hybrid stent graft™ (JOTEC GmbH, Hechingen, Germany), followed with TEVAR, distal landing zone 5 cm above the celiac trunk with persistent retrograde reperfusion of the false lumen. She presented 4 months later with sudden onset of chest and hypotensive requiring resuscitation. Computed tomography angiography (CTA) revealed a complicated false lumen rupture with left-sided hemathorax and aortic true lumen compression. We performed an endovascular bottle neck occlusion with implantation of four Amplatzer-Occluder Vascular Plugs II (AGA)™ and TEVAR distalization of the true lumen directly above the level of the celiac trunk. Second Case: A 58-year-old male patient underwent aorta ascendens replacement in 2004 in TAAD followed by redo bypass surgery in 2013 and frozen elephant trunk E-VITA™ hybrid grafting in 2019. On the 3rd postoperative day, CTA showed a false lumen rupture and a true lumen collapse. As emergent case the patient underwent an extended true lumen TEVAR to the celiac trunk. Inflow occlusion into the false lumen was achieved with Candy Plug implantation (Bolton/Vascutek CMD 44 mm × 100 mm × 44 mm) and Amplatzer-Occluder Vascular Plugs II (AGA)™ (22 mm × 18 mm), 1 cm proximal to the celiac trunk. Results: The procedure times were 168 and 235 min, respectively. The mean fluoroscopy times were 24/46 min, respectively. The amounts of contrast dye used were 250 and 276 ml, respectively. The technical success rate was 100% and no intraprocedural complications occurred. Both patients showed complete thrombosis of the treated ruptured false lumen in the postoperative CTA. The postoperative course was uneventful without stroke, paraplegia, myocardial infarction, or renal failure. After a follow-up of 3 months, both patients are alive and well. Conclusion: Emergency endovascular false lumen occlusion is an important technique in the armamentarium of specialized centers for aortic endovascular therapy to control bleeding and initiate false lumen thrombosis in the management of ruptured aortic dissection. Further cases (multicenter study) and follow-up are needed to consolidate these early results.

Publication History

Article published online:
26 April 2021