A single-center experience treating renal malperfusion after aortic dissection with central aortic fenestration and renal artery stenting

(online only). Intravascular ultrasound imaging (IVUS) of the thoracic aorta of a patient with an acute type B aortic dissection. A, The false lumen is hyperechoic and fully distended, obliterating the true lumen of the aorta except for a slit-like envelope anteriorly. B, In this image of the same patient's left renal artery, the left renal artery appears to arise from the false lumen, but selective arteriography demonstrated that the renal artery was narrowed, but remained tethered to the true lumen. C, IVUS imaging of the thoracic aorta after fenestration and placement of a Wallstent (Boston Scientific). The true lumen has been stented (arrow), with only some continued mild narrowing of the true lumen in the unstented region across the superior mesenteric and bilateral main renal arteries (not illustrated). After aortic fenestration and aortic stenting, a 17 mm Hg systolic gradient was measured across the renal artery origin, despite a re-entry tear at the origin. D, Final IVUS images of the bilateral renal arteries after aortic fenestration, aortic wall stent, and left renal artery stenting. Selective stenting of the left renal artery reduced systolic gradient to 6 mm Hg.

A, Carbon dioxide angiogram of a patient with aortic dissection shows static left renal artery (LRA) obstruction and the true lumen (TL), false lumen (FL), and the dissection flap prolapsing into the left renal artery are well seen. Note that the catheter is in the false lumen. B, Carbon dioxide angiogram of the LRA after fenestration and LRA stenting. C and D, Three-dimensional reformats of the LRA stent (arrow). The true and false aortic lumens are identified. Note the stent extending through the aortic true lumen. E, Cross-sectional computed tomography image of the same patient at the 4-month follow-up. The arrow is directed at the previously placed LRA stent; note the bright and symmetric left renal contrast enhancement supporting adequate perfusion.

Pie graphs illustrate angiographic findings. Top, Right renal arteries arose exclusively from the true lumen in 115 patients (70%), exclusively from the false lumen in 11 (7%), and from both lumens in 37 (23%). Bottom, Left renal arteries arose exclusively from the true lumen in 69 patients (42%), exclusively from the false lumen in 32 (20%), and from both lumens in 62 (38%).

Branch diagram summarizes the endovascular treatment approach in this series of patients, which is related to unilateral or bilateral renal artery obstruction and the nature of such obstruction (ie, static, dynamic, or static + dynamic). Modalities used included isolated unilateral or bilateral renal artery stenting, proximal aortic fenestration with and without aortic stenting, or both renal artery stenting and proximal aortic fenestration with or without aortic stenting. Ao, Aortic; f/s, aortic fenestration. *Implies some additional therapy was used, such as thrombolysis or thrombectomy.

A, Bar graph summarizes the incidence of renal artery obstruction by static or dynamic aortic dissection type, or both; other implies rare cases of fibromuscular dysplasia or atherosclerosis. B, The endovascular approach is summarized by aortic dissection type. Combo, is a combination of modalities; f/s, central aortic fenestration.