1. Menaka Nadar, MD University of Virginia

2. CC: Acute onset abdominal pain HPI: 43 year old male with a history of Marfan’s syndrome presented to outside hospital with acute onset abdominal pain. Transferred for further evaluation after CTA demonstrated acute aortic dissection extending from the left subclavian artery to the left common iliac artery.

3. PMH Marfan’s syndrome PSH Aortic root repair and mechanical AVR for type A aortic dissection in 2007 Pacemaker placement Medications Coumadin for mechanical valve – INR 3.1 on admission Allergies None

4. Imaging Dissection flap involving the left subclavian artery Multiple supraceliac fenestrations Right renal artery from true lumen Left renal artery from false lumen

5. Celiac artery, SMA, and IMA off true lumen Narrowing of true lumen due to compression by false lumen Severe focal narrowing of left common iliac artery

6. Diagnosis/Discussion 43 year old male with Marfan’s syndrome and acute type B dissection – Dissection flap involves left subclavian artery and left common iliac artery – All visceral vessels except left renal artery originate from true lumen – Narrowing of true lumen by compression from false lumen – No evidence of end organ ischemia

7. Potential Complications Paraplegia Stroke Mesenteric ischemia Left upper/lower extremity ischemia Endoleak Stent migration Bleeding (anticoagulated on admission) Mechanical valve thrombus/thromboembolic event (off full anticoagulation periprocedure)

8. Intervention Left carotid to subclavian bypass Thoracic endovascular stent graft x 2 beginning just distal to the left common carotid Abdominal endovascular stent graft Left common iliac artery stent

9. Post-procedure day 1 patient complained of left leg paresthesias. PVRs showed biphasic waveforms bilaterally. ABIs: 0.62 on the right, 0.7 on the left. CTA showed increased narrowing of the true lumen adjacent to the visceral vessels.

10. On postprocedure day 3, IVUS used to advance needle from true lumen into false lumen to create fenestration in dissection flap.

11. Balloon dilatation of fenestration with equal pressures within false and true lumens post procedure. Left leg paresthesias resolved.

12. Summary 43 year old male with Marfan’s syndrome presents with acute aortic dissection from the left subclavian artery to the left common iliac artery with all visceral vessels except left renal artery from narrowed true lumen. Treated with thoracic and abdominal endografts, left common iliac stenting, and left carotid-subclavian bypass. Postprocedure developed left leg paresthesias, worsened narrowing of true lumen, and decreased ABIs, treated with fenestration of the dissection flap.