Placement of a Zenith® Dissection Endovascular System in the Descending Thoracic Aorta Can Hamper Further Surgical Aortic Operations

INTRODUCTION: The efficacy of endovascular treatment for complicated Stanford type B acute aortic dissection is being established. However, aortic events sometimes occur, and some cases require surgical intervention. REPORT: A 52 year old man underwent ascending aorta replacement for Stanford type A acute aortic dissection in August 2016. Post-operative computed tomography (CT) showed residual dissection from the aortic arch to the right common iliac artery and a large re-entry in the right common iliac artery (RCIA). Two months after the operation, CT revealed enlargement of the false lumen of the thoracic aorta and the thoracic aortic diameter. Aiming to reduce the false lumen and remodel the aorta, a three stage operation was performed, as described below. Four months after the dissection, total aortic arch replacement and a frozen elephant trunk insertion were performed as the first stage. Subsequently, as a second stage operation, thoracic endovascular repair (TEVAR) was performed using a Zenith® Dissection Endovascular System (Cook Japan Co., Ltd, Tokyo, Japan), with the aim of expanding the true aortic lumen. The implanted devices were a stent graft for the proximal part and two bare stents for the middle and distal part. As a third stage operation, abdominal aortic endovascular treatment was performed with the purpose of closing the re-entry from the RCIA. However, two years after the three stage operation, CT showed that the thoracic aorta was over 60 mm in diameter. Graft replacement of the thoraco-abdominal aorta was performed. The bare stents were expected to be easily removable from the aorta, but unexpectedly, they were strongly attached to the intima, which made it extremely difficult to perform surgical and aortic operations. DISCUSSION: Surgical operations for the aorta can become more difficult after bare stent placement in the aorta.