Single-stage total thoracoabdominal endovascular repair for acute non-A non-B aortic dissection with retrograde extension to the ascending aorta and concomitant abdominal dissecting aneurysm: a case report.
急性非A非B型主动脉夹层是一种复杂且高风险的疾病。传统治疗方案要求，凡累及升主动脉的夹层（Stanford A型或DeBakey I/II型）均须行急诊开放手术修复。随着血管腔内器械的不断进步，微创方案正逐渐成为部分累及升主动脉的高危患者的可行替代选择，可能较全主动脉弓置换具有一定优势。患者为73岁男性，因胸背部疼痛1周就诊，诊断为急性非A非B型主动脉夹层，主要破口位于降主动脉（Ishimaru 3区），并逆行延伸至升主动脉。计算机断层血管造影及三维重建显示：急性非A非B型主动脉夹层，主要破口位于Ishimaru 3区，逆行延伸至升主动脉根部，顺行延伸至髂动脉分叉处。左肾动脉完全起源于假腔，腹部夹层性主动脉瘤最大直径为61 mm。由于患者在症状出现前未接受过任何主动脉影像学检查，无法明确判断该病变为既往存在的动脉瘤，还是慢性夹层性动脉瘤伴继发性假腔扩张。根据从胸主动脉连续延伸至肾下段的夹层内膜片以及部分假腔血栓形成，我们倾向于认为61 mm的扩张是急性夹层后假腔动脉瘤样退变所致。鉴于内脏段动脉瘤病变符合既定的干预标准，且分期修复存在间期破裂风险，经充分讨论并应患者家属要求，行单期全腔内重建。重建范围自左颈总动脉起源远端水平至髂动脉分叉处。置入医师改良覆膜支架，并将开窗精准对齐左锁骨下动脉开口，经该开窗置入Viabahn覆膜支架以重建左锁骨下动脉血运。对于内脏段，使用第二枚医师改良开窗覆膜支架，其四个开窗分别对应腹腔干、肠系膜上动脉及双侧肾动脉，各分支均以Viabahn覆膜支架重建。患者术后恢复顺利，无截瘫征象，术后1周出院。随访1年时，观察到满意的主动脉重塑及分支血管通畅。本病例报告描述了一例急性非A非B型主动脉夹层合并腹主动脉瘤的患者，经单期腔内修复后获得良好结局。患者术后未发生截瘫，且在近端胸主动脉破口封闭后，升主动脉壁内血肿消退并发生良好的重塑。本病例提示，对于开放胸科手术高风险的患者，单期腔内修复可作为替代治疗选择。
Acute non‑A non‑B aortic dissection represents a complex and high-risk condition. Traditional treatment protocols mandate emergency open surgical repair for any dissection involving the ascending aorta (Stanford Type A or DeBakey Type I/II). With ongoing advancements in endovascular devices, less invasive options are emerging as viable alternatives for select high-risk patients with ascending aortic involvement, potentially offering advantages over total arch replacement. A 73-year-old male presented with one week of chest and back pain and was diagnosed with acute non‑A non‑B aortic dissection with the primary entry tear located in the descending aorta (Ishimaru zone 3) extending retrogradely to the ascending aorta. Computed tomography angiography and three-dimensional reconstruction revealed an acute non‑A non‑B aortic dissection with a primary entry tear located at the Ishimaru zone 3, extending retrograde to the root of the ascending aorta and antegrade to the bifurcation of the iliac arteries. The left renal artery originated entirely from the false lumen, and the abdominal dissecting aortic aneurysm had a maximum diameter of 61 mm.Because the patient had not undergone any aortic imaging before symptom onset, it is not possible to definitively determine whether this lesion represents a pre-existing aneurysm or a chronic dissecting aneurysm with secondary false lumen dilatation. Based on the continuous dissection flap extending from the thoracic aorta into the infrarenal segment and the presence of partial false lumen thrombosis, we tend to favor that the 61 mm dilatation represents false lumen aneurysmal degeneration following the acute dissection. Given that the aneurysmal lesions in the visceral segment met established criteria for intervention and that staged repair carried a risk of interval rupture, a single-stage total endovascular reconstruction was performed following thorough discussion and at the request of the patient's family. The reconstruction extended from the level distal to the origin of the left common carotid artery to the iliac bifurcation. A physician-modified endograft was deployed, and a fenestration was precisely aligned with the origin of the left subclavian artery, through which a Viabahn covered stent was placed to revascularize the left subclavian artery. For the visceral segment, a second physician-modified fenestrated stent graft with four fenestrations corresponding to the celiac artery, superior mesenteric artery, and bilateral renal arteries was used, with each branch reconstructed using a Viabahn covered stent. The patient recovered smoothly after surgery, with no signs of paraplegia, and was discharged one week post-surgery. At 1-year follow-up, satisfactory aortic remodeling and branch vessel patency were observed. This case report describes a patient with acute non‑A non‑B aortic dissection complicated by an abdominal aortic aneurysm who achieved a favorable outcome following single-stage endovascular repair. The patient did not develop paraplegia postoperatively, and following occlusion of the proximal thoracic aortic entry tear, the ascending aortic intramural hematoma resolved and underwent favorable remodeling. This case suggests that single-stage endovascular repair may serve as an alternative treatment option for patients at high risk for open thoracic surgery.
Xiaojun Shu, Zuyue Huang, Dan Zhou, Yonglong Wang, Weijian Chen, Zhengfei Li, et al. Single-stage total thoracoabdominal endovascular repair for acute non-A non-B aortic dissection with retrograde extension to the ascending aorta and concomitant abdominal dissecting aneurysm: a case report.. Journal of cardiothoracic surgery. 2026; doi:10.1186/s13019-026-04553-4.
Xiaojun Shu, Zuyue Huang, Dan Zhou, Yonglong Wang, Weijian Chen, Zhengfei Li, et al (2026). Single-stage total thoracoabdominal endovascular repair for acute non-A non-B aortic dissection with retrograde extension to the ascending aorta and concomitant abdominal dissecting aneurysm: a case report.. Journal of cardiothoracic surgery. https://doi.org/10.1186/s13019-026-04553-4
Xiaojun Shu, Zuyue Huang, Dan Zhou, Yonglong Wang, Weijian Chen, Zhengfei Li, et al. Single-stage total thoracoabdominal endovascular repair for acute non-A non-B aortic dissection with retrograde extension to the ascending aorta and concomitant abdominal dissecting aneurysm: a case report.[J]. Journal of cardiothoracic surgery, 2026 doi:10.1186/s13019-026-04553-4.
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