TREATMENT OF NON-A NON-B ACUTE AORTIC DISSECTION WITH THORACIC DEBRANCHING, TEVAR, AND CROSS- FEMORAL BYPASS: A CASE PRESENTATION
15. INTERNATIONAL CONGRESS ON HEALTH SCIENCES AND EMERGENCY MEDICAL SERVICES, İzmir, Türkiye, 26 - 28 Ekim 2025, ss.67-69, (Tam Metin Bildiri)
- Yayın Türü: Bildiri / Tam Metin Bildiri
- Doi Numarası: 10.30546/19023.9789952-8605-3-5.2025.349
- Basıldığı Şehir: İzmir
- Basıldığı Ülke: Türkiye
- Sayfa Sayıları: ss.67-69
- Recep Tayyip Erdoğan Üniversitesi Adresli: Evet
Özet
Aortic dissection is a life-threatening condition characterized by the entry of blood into the media layer of the aortic wall through a tear in the intima, leading to a sudden onset clinical picture with high mortality risk. It is commonly classified according to the Stanford and DeBakey classification systems. Stanford Type A dissection involves the ascending aorta and requires emergency surgical intervention. Stanford Type B dissection involves only the descending aorta and is typically managed with medical therapy or endovascular intervention. Non-A Non-B dissection refers to dissections that do not involve the ascending aorta but include the aortic arch, thus falling outside the classical classification. Due to their anatomical location, these dissections pose challenges for both surgical and endovascular treatment. Non-A Non-B dissections may not be adequately managed with surgery or endovascular repair alone. Therefore, in recent years, hybrid approaches (debranching + TEVAR) have gained increasing importance. This presentation discusses the management and follow-up of a patient who presented to the emergency department with a Non-A Non-B dissection. A 28-year-old male patient with no known comorbidities presented to an external emergency department with sudden onset chest and back pain. A contrast-enhanced thoracoabdominal CT angiography revealed a dissection flap, and the patient was referred to our hospital. On physical examination, upper extremity pulses were palpable, while distal pulses in the lower extremities were absent. No motor deficit or signs of acute ischemia were noted in the lower limbs. Neurological examination was normal, and the patient was conscious. CT angiography showed a dissection flap extending from the distal origin of the left carotid artery into the descending aorta, while the innominate artery and left carotid artery were spared. Emergency surgery was planned. In the first stage of the operation, thoracic debranching was performed. A Dacron Y-graft was used to bypass from the ascending aorta to the innominate and left common carotid arteries, and a separate Dacron graft was used to bypass from the left carotid to the left subclavian artery. This was followed by a TEVAR procedure. An endovascular stent-graft was deployed starting just distal to the Y-graft and extending into the aortic arch. Control aortography confirmed patency of the debranching grafts. Following the procedure, bilateral distal pulses in the lower extremities were palpable. Postoperatively, the patient was admitted to the intensive care unit for monitoring. During ICU follow-up, distal pulses in the left lower extremity were lost, and a right to-left cross-femoral bypass was performed. The postoperative course was uneventful; the patient stayed in the ICU for 4 days and was then transferred to the ward for another 4 days before being discharged in good condition. Approximately one month later, the patient presented to the outpatient clinic with complaints of fatigue and fever. Blood cultures grew gram-positive cocci, although imaging studies did not reveal any surgical site infection. After antibiotic treatment, the patient was discharged without further complications. Non-A Non-B dissections may not be adequately treated with standard surgical or endovascular techniques alone due to their anatomical location. Therefore, hybrid approaches have come to the forefront. Securing the supra-aortic branches through debranching followed by TEVAR offers an effective treatment strategy in arch-involving dissections. When necessary, additional revascularization (e.g., cross-femoral bypass) can restore lower extremity perfusion. The combination of thoracic debranching and TEVAR represents a safe and effective treatment option in Non-A Non-B dissections. Despite the potential need for additional interventions, a multidisciplinary approach can reduce morbidity and mortality. As demonstrated in this young patient, successful outcomes can be achieved with appropriate surgical planning.