Abstract 4370167: Endovascular Management of Stanford B Aortic Dissection in a Young Patient with a Thoracoabdominal Aneurysm: A Viable Strategy?

Abstract

Patient presentation: A 35-year-old woman arrived at the emergency department with a five-month history of intermittent interscapular pain, which evolved hours before admission into severe, transfictive left-sided chest pain radiating to the epigastrium, with fatigue and dyspnoea. Physical exam revealed a prominent suprasternal notch mass and bilateral carotid systolic murmurs with thrill. Past medical history included gestational hypertension (2022). Vitals on admission: BP 157/110 mmHg, HR 97 bpm, RR 19, SpO2 91%. Initial workup: Chest X-ray showed mediastinal widening. CT angiography revealed a fusiform thoracoabdominal aortic aneurysm (89 × 85 mm, 221 mm length) from T6 to L2, with a dissection flap from the coeliac trunk to the infrarenal segment (Stanford B, DeBakey III), plus intramural thrombus and mural calcifications. A 10 mm flap in the proximal coeliac trunk and an intimal tear at the origin of the left subclavian artery (extending 54 mm) were also seen. Additional findings: left pleural effusion and hepatic haemangiomas. Diagnosis and management: Diagnosis: thoracoabdominal aneurysm with Stanford B, DeBakey IIB dissection. Medical management: IV nitroprusside, esmolol, and analgesia. Due to high rupture risk, endovascular repair was chosen over open surgery. Via right femoral access, two endografts were deployed in the thoracic/abdominal aorta. The left subclavian artery, arising from the false lumen, was not fenestrated. The procedure involved bleeding requiring transfusion, but no further complications. Follow-up: Three days later, the patient presented abdominal pain and hemoglobin drop. CT suggested a type IA endoleak, sealed endovascularly. A left carotid-subclavian bypass was later performed. Echocardiogram revealed a bicuspid aortic valve with moderate regurgitation. After 12 days, the patient was discharged in improvement, on beta-blocker and antiplatelet therapy, and continues follow-up. Conclusion: This case highlights the importance of early diagnosis and tailored management of Stanford B dissection with thoracoabdominal aneurysm in young patients. Bicuspid valve anatomy predisposes to aortic disease, requiring close surveillance. Despite ongoing debate, TEVAR proved effective here, especially in experienced hybrid centers.