TEVAR for Type B aortic dissection with right-sided aortic arch and left subclavian vascular ring

Abstract

Background

Embryological aortic development is characteristically asymmetric, and as such, abnormalities in formation can present unique issues. Right-sided aortic arch is one such variant; repairing acute pathologies in this population requires technical and anatomic proficiency. Yet given the rarity of these conditions, there are few evidence-based guidelines outlining proper interventional management. This case serves as a demonstration of successful endovascular repair of a Stanford type B dissection in the setting of right aortic arch and congenital vascular ring.

Case summary

An 82-year-old female with a past medical history of hypertension, status-post coronary artery bypass grafting, presented to the emergency department (ED) with acute onset severe back and chest pain. An urgent computerized tomography angiography (CTA) subsequently revealed a type B aortic dissection with aberrant RAA anatomy along with a vascular ring. Due to hemodynamic instability and concern for hemothorax, the patient was taken emergently to the operative theater for endovascular repair and was successfully treated with a single aortic stent graft. Follow-up CTA 1 month later showed a proximal type I endoleak, and in efforts to promote remodeling, the repair was extended to the proximal descending aorta with coil embolization of the vascular ring.

Discussion

In patients with Type B dissection in the setting of right-sided aortic arch, surgical versus endovascular approaches are influenced by anatomic understanding and technical feasibility. This case serves as an example of a successful endovascular repair in an abnormal aortic environment, which may potentially reduce post-procedure morbidities compared to open surgery.