Successful Primary PCI in Stanford Type A Aortic Dissection Complicated by Inferior ST-Elevation Myocardial Infarction: A Case in a Facility with No Surgical Backup.

Mortality of type A aortic dissection (TAAD) complicated with coronary malperfusion syndrome is very high even when emergency surgery is performed. Several reports suggested that primary percutaneous coronary intervention (PPCI) followed by immediate corrective surgery may reduce mortality. In many countries, immediate transfer to an aortic surgery center may not be possible. We report a case of TAAD complicated by coronary malperfusion successfully treated with PPCI followed by elective corrective surgery. A 48-year-old man was referred to emergency department with acute inferior ST-elevation myocardial infarction (STEMI) and underwent PPCI. During the procedure, we realized that the cause of STEMI was TAAD. We decided to continue because the patient experienced seizures and bradycardia. Subsequently, echocardiography and computed tomography confirmed the dissection. The patient was discharged and referred to the National Cardiovascular Center where he underwent successful elective surgery. In this patient, immediate revascularization was lifesaving and served as a bridging procedure before surgical correction.

Association of metformin use with abdominal aortic aneurysm: A systematic review and meta-analysis.

BACKGROUND: Abdominal aortic aneurysm (AAA) is a cardiovascular disease characterized by a high mortality rate when ruptured. Some studies suggest a potential inverse correlation between AAA and diabetes patients, especially those undergoing metformin treatment. However, this relationship remains unclear. This paper offers a systematic review and meta-analysis with the objective of clarifying the influence of metformin on AAA. METHODS: A search for relevant articles was performed across multiple databases including PubMed, ScienceDirect, Cochrane and Scopus. The focus was on studies that examined the comparative effects of metformin and non-metformin treatments on AAA patients. Data from appropriate studies were consolidated to estimate the effects. Our study encompassed 11 articles, comprising 13 cohorts that compared metformin (n = 32,250) with a control group (n = 116,339). RESULTS: The random effects meta-analysis revealed that metformin was associated with a slower growth rate (weighted mean difference (WMD) -0.86 mm; 95% CI: -1.21 to -0.52; p < 0.01; I2: 81.4%) and fewer AAA-related events (OR: 0.54; 95% CI: 0.34 to 0.86; p = 0.01; I2: 60.9%). The findings suggest that metformin may be linked to a reduced risk of aortic aneurysm. A meta-regression analysis indicated that the association between metformin and AAA growth was significantly influenced by male gender (p = 0.027), but not by age (p = 0.801), hypertension (p = 0.256), DM (p = 0.689), smoking history (p = 0.786), use of lipid-lowering agents (p = 0.715), or baseline diameter (p = 0.291). CONCLUSION: These results hint at a potential role for metformin in limiting annual AAA growth, AAA-related events, and the risk of AAA.

Successful Ovarian Vein Embolization of a Multiparous Woman with Pelvic Congestion Syndrome.

Pelvic congestion syndrome (PCS) is a clinical syndrome supported by specific findings, such as ovarian vein's dilatation, that cause pelvic vein congestion. Although many theories are explaining the pathophysiologies of this condition, the underlying cause remains unknown. The clinical manifestations of PCS are various including chronic pelvic pain (CPP), voiding disturbances, or ureteral obstruction. Imaging modality, such as ultrasonography, computed tomography (CT scan), magnetic resonance imaging (MRI), and venography, are needed to confirm and exclude the differential diagnosis. Currently, American venous forum guidelines recommended endovascular therapy which is percutaneous embolization as the first option therapy of PCS. Here, we reported a 35-year-old woman with PCS who underwent successful percutaneous embolization therapy.

Acute Limb Ischemia in COVID-19: A Systematic Review.

Numerous studies have reported cases of acute limb ischemia (ALI) in coronavirus disease 2019 (COVID-19), along with a sharp increase of ALI incidence during the COVID-19 pandemic. The objective of this study was to analyze the clinical features, treatment strategies, and outcomes in COVID-19 patients who developed ALI. A systematic search was performed in PubMed, ScienceDirect, and Cochrane to identify relevant articles. Variables of interest included ALI location, ALI and COVID-19 severity, concomitant thrombosis, comorbidities/risk factors, coagulation and inflammatory parameters, therapy, outcome, and cause of death. Data extraction and pooling were conducted by two reviewers. Fifty-six articles with a total of 191 subjects were included in the analysis; 78.5% of the subjects were male; mean age was 64.2 years; 94.2% of cases were ALI de novo; 41.1% of the subjects had ALI stage IIB; 82.7% of ALI occurred in the lower limb. The popliteal artery was the most commonly affected artery (48.2% of subjects); 38.1% of the subjects had severe COVID-19; 11.1% had asymptomatic COVID-19, and 15.9% were post-COVID-19; 50.7% of the subjects had hypertension; 12.0% of the subjects had concomitant thrombosis; 98.1% of the subjects had elevated D-dimer, and 83.3% of the subjects had elevated C-reactive protein; 61.9% of the subjects underwent surgical thromboembolectomy, 21.3% underwent conservative treatment, and 8.1% underwent amputation initially. The overall mortality rate and limb amputation rate were 39.3 and 22.4%, respectively; 67.6% of deaths were due to respiratory failure. Our study supports that COVID-19 is associated with hypercoagulability that may trigger the development of ALI, and that ALI is a possible predictor of poor outcome in COVID-19 patients.

Gender Differences of Gly972Arg Polymorphism of the IRS-1 Gene Related to Cardiovascular Disease Risk Factors Among Indonesians.

BACKGROUND: Cardiovascular disease is driven by traditional risk factors, sex, and genetic differences. The Asian population, specifically Indonesians, has been known at high risk of insulin resistance and endothelial dysfunction. A possible genetic risk factor related to cardiovascular diseases is Gly972Arg polymorphism of insulin receptor substrate 1 (IRS-1) gene, as this impairs endothelial function. To date, whether there is a gender difference in Gly972Arg polymorphism of the IRS-1 gene in Indonesians is unknown. This study aimed to to define whether there is a gender difference in Gly972Arg polymorphism of the IRS-1 gene in Indonesians. METHODS: We studied adults living in two areas (rural and urban) in Indonesia. We collected demographic and clinical data from the study subjects. Gly972Arg polymorphism of the IRS-1 gene (rs1801278) was detected using TaqMan real-time polymerase chain reaction. RESULTS: A total of 378 subjects were recruited. The wild-type allele (CC) was found in 86 (22.8%) subjects, heterozygous mutant allele (CT) in 245 (64.8%), and homozygous mutant allele in 47 (12.4%). The proportion of subjects with T alleles was significantly higher among women than men (54.6% vs. 45.4%, odds ratio: 1.89; p = 0.01). Subjects with T allele more often have hypertension (odds ratio: 1.69, p = 0.058). CONCLUSION: There were a higher proportion of women than men carrying the T allele of Gly972Arg polymorphism among Indonesians. Individuals with the T allele appeared to show a greater prevalence of hypertension. These results may explain a possible mechanism of the high prevalence of metabolic syndrome in Indonesia, especially in women.

Predicting multi-vascular diseases in patients with coronary artery disease.

Background: Because of its systemic nature, the occurrence of atherosclerosis in the coronary arteries can also indicate a risk for other vascular diseases.  However, screening program targeted for all patients with coronary artery disease (CAD) is highly ineffective and no studies have assessed the risk factors for developing multi-vascular diseases in general. This study constructed a predictive model and scoring system to enable targeted screening for multi-vascular diseases in CAD patients. Methods: This cross-sectional study includes patients with CAD, as diagnosed during coronary angiography or percutaneous coronary intervention from March 2021 to December 2021. Coronary artery stenosis (CAS) and abdominal aortic aneurysm (AAA) were diagnosed using Doppler ultrasound while peripheral artery disease (PAD) was diagnosed based on ABI score. Multivariate logistic regression was conducted to construct the predictive model and risk scores. Validation was conducted using ROC analysis and Hosmer-Lemeshow test. Results: Multivariate analysis showed that ages of >60 years (OR [95% CI] = 1.579 [1.153-2.164]), diabetes mellitus (OR = 1.412 [1.036-1.924]), cerebrovascular disease (OR = 3.656 [2.326-5.747]), and CAD3VD (OR = 1.960 [1.250-3.073]) increased the odds for multi-vascular disease. The model demonstrated good predictive capability (AUC = 0.659) and was well-calibrated (Hosmer-Lemeshow p = 0.379). Targeted screening for high-risk patients reduced the number needed to screen (NNS) from 6 in the general population to 3 and has a high specificity of 96.5% Conclusions: Targeted screening using clinical risk scores was able to decrease NNS with good predictive capability and high specificity.

Understanding Arteriosclerotic Heart Disease Patients Using Electronic Health Records: A Machine Learning and Shapley Additive exPlanations Approach.

OBJECTIVES: The number of deaths from cardiovascular disease is projected to reach 23.3 million by 2030. As a contribution to preventing this phenomenon, this paper proposed a machine learning (ML) model to predict patients with arteriosclerotic heart disease (AHD). We also interpreted the prediction model results based on the ML approach and deployed modelagnostic ML methods to identify informative features and their interpretations. METHODS: We used a hematology Electronic Health Record (EHR) with information on erythrocytes, hematocrit, hemoglobin, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, leukocytes, thrombocytes, age, and sex. To detect and predict AHD, we explored random forest (RF), XGBoost, and AdaBoost models. We examined the prediction model results based on the confusion matrix and accuracy measures. We used the Shapley Additive exPlanations (SHAP) framework to interpret the ML model and quantify the contribution of features to predictions. RESULTS: Our study included data from 6,837 patients, with 4,702 records from patients diagnosed with AHD and 2,135 records from patients without an AHD diagnosis. AdaBoost outperformed RF and XGBoost, achieving an accuracy of 0.78, precision of 0.82, F1-score of 0.85, and recall of 0.88. According to the SHAP summary bar plot method, hemoglobin was the most important attribute for detecting and predicting AHD patients. The SHAP local interpretability bar plot revealed that hemoglobin and mean corpuscular hemoglobin concentration had positive impacts on AHD prediction based on a single observation. CONCLUSIONS: ML models based on real clinical data can be used to predict AHD.

Palliative interatrial septum stenting with a vascular stent in a chronic thromboembolic pulmonary hypertension patient: Is it beneficial?

BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious disease that can progress and lead to a deadly outcome. Despite optimal drug therapy, pulmonary hypertension (PH) remains fatal. Untreatable right heart failure (RHF) from CTEPH is eventually a significant cause of death. However, unloading the right heart and increasing systemic output are the treatment goals in these patients. CASE PRESENTATION: A 42-year-old female presented to the emergency department with worsening dyspnea experienced for three days before admission. There were also complaints of leg edema, ascites, orthopnea, and palpitation. Physical examination revealed an attenuated second heart sound, abdominal ascites, and bilateral leg edema. She had a history of frequent readmissions due to RHF despite optimal medical therapy and was diagnosed with CTEPH 5 months ago. It was decided that the patient would undergo interatrial septal (IAS) stenting with a vascular stent of 8 mm × 39 mm × 135 cm. The results were good; her symptoms and signs of RHF improved, and she was eventually discharged from the hospital. Four months after the procedure, the patient was able to engage in physical activities without any limitations. CONCLUSIONS: A palliative IAS stent is one of the choices for intractable RHF management in patients with CTEPH. The vascular stent can be used as an alternative in order to make the interatrial connection more stable and last longer.

Catastrophic Concomitant Arterial and Venous Thrombosis in a Mild COVID-19-Positive Patient.

Since its first discovery in late 2019, coronavirus disease 2019 (COVID-19) has been a global burden associated with significant morbidity and mortality. COVID-19 has been correlated with the development of hypercoagulable state that predisposes the patients to a higher risk of thromboembolism. Current evidence suggests higher incidence of thrombosis, particularly venous thrombosis, among hospitalized COVID-19 patients, mostly with critical illness. On the other hand, there is currently no data regarding the incidence of vivid thrombosis in ambulatory patients with mild COVID-19 and the incidence of concomitant arterial and venous thrombosis in COVID-19 is extremely rare. Herein, we describe catastrophic outcomes of concomitant lower limb arterial and venous thrombosis in a patient with mild COVID-19. This report highlights the occurrence of concomitant arterial and venous thrombosis in ambulatory setting and that this phenomenon resulted in catastrophic clinical consequences.

Acute Limb Ischemia after Cardiovascular Surgery: A Deadly Duo Combination with High Mortality.

Acute limb ischemia (ALI) is a predictor of high morbidity and mortality. Previous studies showed that ALI developed after cardiac surgery may increase mortality. This study aimed to elucidate the clinical course and identify risk factors contributing to mortality in patients with ALI after cardiovascular surgery. This is a single-center retrospective cohort study. We analyzed data from 52 patients with ALI after cardiovascular surgery between 2016 and 2020. We evaluated the risk factors for 1-year mortality using Cox proportional hazards regression analysis. Most of the patients with ALI were male and the median age was 56 years (23-72 years). Most of the patients with ALI had coronary artery diseases. The 1-year mortality rate was 55.8% ( n = 29 patients). Multivariable analysis revealed that cardiopulmonary bypass (CPB) time ≥ 100 minutes (hazard ratio [HR]: 3.067, 95% confidence interval [CI]: 1.158-8.120) and postoperative acute kidney injury (HR: 2.927, 95% CI: 1.358-6.305) were significantly increasing the risk of mortality in patients with ALI after an operation. ALI after cardiovascular surgery was associated with high 1-year mortality in our study and long CPB time and postoperative acute kidney injury contributed to the mortality.

Recanalization of occluded central veins in hemodialysis patients using a dual lumen microcatheter.

BACKGROUND: Percutaneous transluminal angioplasty (PTA) is the standard therapy for stenosis or occlusion of the central vein in patients with chronic kidney disease undergoing routine hemodialysis. In the case of chronic total occlusion (CTO) of the central vein, crossing the lesion might be the most challenging part of the procedure. Although several techniques have been successfully used, a new, additional strategy that is safer yet equally effective would be beneficial. METHODS: We reported two cases of central vein occlusion in which the lesions could not be crossed by multiple escalating wires even with the support of a microcatheter. The wires could not penetrate the hardest part of the lesion and were always deflected to the false route. A dual lumen microcatheter was used as a support for the first wire and to facilitate the insertion of a second wire through the chronic occlusion. RESULTS: The dual lumen microcatheter successfully facilitated wire crossing of the CTO lesion in two patients. CONCLUSIONS: Dual lumen microcatheters may serve as an alternative strategy to cross central vein occlusions during PTA.

Post-Bentall procedure 'pseudo' pulmonary embolism, cardiac tamponade in disguise: a case report.

Background: Post-operative cardiac complications require rapid evaluation, which may be hindered by various challenges. Sudden shortness of breath with persisting haemodynamic failure after cardiac procedure is often associated with cases of pulmonary embolism or cardiac tamponade that have contradicting therapies. Anticoagulant therapy is the treatment of choice for pulmonary embolism; however, it could worsen pericardial effusion where bleeding control and clot evacuation are the mainstays of treatment. In this study, we present a case of late cardiac complication due to cardiac tamponade mimicking signs of pulmonary embolism. Case summary: A 45-year-old male with aortic dissection DeBakey type-II, 7 day post-Bentall procedure, presented with sudden shortness of breath and persistent shock despite therapy. Initial assessment directed towards pulmonary embolism was supported by hallmark imaging signs from X-ray and transthoracic echocardiography evaluation. However, computed tomography scan results were suggestive of cardiac tamponade mainly accumulating at the right side of the heart, compressing the pulmonary artery and vena cava confirmed by transoesophageal echocardiography, thus mimicking the findings of pulmonary embolism. After clot evacuation procedure, the patient improved clinically and was discharged the following week. Discussion: In this study, we highlight a case of cardiac tamponade with classical findings of pulmonary embolism after an aortic replacement procedure. Physicians should carefully analyse a patient's clinical history, physical, and supporting examinations to direct and change the course of therapy accordingly, as these two complications have opposite therapy principles and may exacerbate the patient's condition.

5-Year Follow-Up of Endovascular Management in a Patient with Chronic Concomitant DeBakey Type II and IIIa Aortic Dissection.

The incidence of chronic concomitant DeBakey Type II and IIIa aortic dissection is uncommon and complex. Since the mortality rate is very high, it requires a precise and holistic treatment plan. In some cases, when the patients refuse to undergo open surgery or the patients' condition is not suitable for open surgery, thoracic endovascular aortic repair (TEVAR) is the recommended therapeutic approach. In this case, a patient refused to undergo open surgery and chose TEVAR instead. The patient survived the procedure and lived for years. We present the case of a successful TEVAR procedure in a patient with chronic concomitant DeBakey Type II and IIIa aortic dissection in a 51-year-old man and the 5-year postoperative follow-up of the patient's condition.

Clinical and Hemodynamic Factors Associated with Low Gradient Severe Rheumatic Mitral Stenosis.

Discrepancy between narrowed mitral valve area and transmitral gradient is not uncommon, suggesting the presence of low gradient (LG)-severe mitral stenosis (MS). Some clinical and hemodynamic factors are believed to associate with LG-severe MS. Transthoracic echocardiography reports were reviewed retrospectively to evaluate the association of all clinical and hemodynamic parameters with LG-severe MS. A 36% of total 322 patients was in the LG-severe MS group. In multivariate analysis, atrial fibrillation (95% confidence interval [CI] 4.60-16.71, odds ratio [OR] 8.77), net atrioventricular compliance > 4 mL/mm Hg (95% CI 3.96-14.25, OR 7.51), tricuspid regurgitation maximal velocity (TR Vmax) > 3.4 m/s (95% CI 0.13-0.48, OR 0.25), stroke volume index ≤ 35 mL/m 2 (95% CI 1.49-6.25, OR 3.05), female gender (95% CI 1.30-5.33, OR 2.63), and severe tricuspid regurgitation (95% CI 1.04-5.50, OR 2.39) were found to be associated with LG-severe MS. Atrial fibrillation, net atrioventricular compliance, TR Vmax, stroke volume index, female gender, and severe TR were associated with low transmitral gradient in patients with severe MS.

A Novel Peptide Elabela is Associated with Hypertension-Related Subclinical Atherosclerosis.

INTRODUCTION: Elabela is a newly identified peptide which, alongside apelin, acts as an endogenous ligand that activates the angiotensin receptor-like 1 receptor. Previous studies have shown the association of elabela with hypertension, but information about the role of elabela in hypertension-related subclinical atherosclerosis is scarce. AIM: We aimed to determine the elabela levels in hypertensive patients and explore its association with subclinical atherosclerosis. METHODS: A total of 104 subjects with hypertension were included in the study. Elabela levels were measured using an enzyme-linked immunosorbent assay, by first extracting the peptide following the manufacturer's instructions. Subclinical atherosclerosis was assessed by measuring the carotid intima-media thickness (IMT) using ultrasound. RESULTS: Compared to stage 1, elabela levels decreased in stage 2 hypertension (0.23 [0.13, 0.45] ng/ml vs. 0.14 [0.09, 0.23] ng/ml; P = 0.000), and in the group with increased carotid IMT compared to normal IMT (0.24 [0.13, 0.38] ng/ml vs. 0.15 [0.10, 0.23] ng/ml; P = 0.005). Additionally, a linear correlation analysis showed that elabela had a significant negative correlation with systolic blood pressure (r = - 0.340, P = 0.000) and carotid IMT (r = - 0.213; P = 0.030). In multivariate analysis, lower elabela levels were associated with a higher cardiovascular risk group in this study (OR 5.0, 95% CI 1.8-13.5, P < 0.001). CONCLUSIONS: This study demonstrated for the first time that circulating elabela declined in a higher stage of hypertension and hypertensive patients with increased carotid IMT, implicating that elabela may be involved in the pathogenesis of hypertension-associated subclinical atherosclerosis.

Endovascular management of aortic aneurysm with severe neck angulation and/or iliac artery tortuosity using multiple stiff wire technique: a case series.

Background: Suitable aortic neck is one of the essential components for thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR). Advanced techniques were developed to adjust and compromise the aneurysm neck angulation but with adding additional devices and complexity to the procedure. We proposed a simple technique to modify severe neck angulation and/or iliac artery tortuosity by using the multiple stiff wire (MSW) technique. Method: Two femoral accesses were required for the MSW technique. A guidewire with a support catheter was inserted through the right and left femoral arteries and positioned in the abdominal or thoracic aorta. Wire exchanges were done with extra stiff wire in both femoral accesses. It can be considered to add multiple stiff wires to align the torturous neck / iliac artery. Delivery of the stent graft main body can be done via one of the accesses. Result: Six patients with different aortic pathology were admitted to our hospital. Four patients undergo EVAR procedure and two patients undergo TEVAR procedure. All patients had aortic neck angulation problems with one patient having iliac artery tortuosity. MSW technique was performed on the patients with good results. Follow-up CTA after 3 months revealed a good stent position without stent migration and no endoleak was found in all but one patient. Conclusion: MSW technique is a simple and effective technique to modify aortic neck/iliac artery angulation in TEVAR or EVAR procedure.

Acute Embolic Occlusion of Renal Artery after the Bentall Procedure: the Role of Primary Renal Angioplasty.

Acute renal occlusion is an uncommon emergency problem in daily practice. The diagnosis is often missed or delayed not only because of its rarity but also nonspecific of clinical presentation. Sudden and complete termination of arterial blood supply to the kidney may lead to renal infarction and a complete loss of renal function. Although the need of early revascularization is uniformly recommended, but the methods has not been established. We presented a case of acute thromboembolic renal artery occlusion in patient who had a history of Bentall's surgery. Renal infarction and artery occlusion were clearly visualized by computed tomography angiogram (CTA). The patient was successfully treated with angioplasty and stenting of main renal artery with complete disappearance of symptoms and recovery of his renal function.

Ischemic Complications Following Thoracic Endovascular Aortic Repair with and Without Revascularization of Left Subclavian Artery: A Systematic Review and Meta-Analysis.

BACKGROUND: Thoracic Endovascular Aortic Repair has been widely performed to treat various thoracic aortic pathologies. However, stent-graft placement in the thoracic aorta may result in left subclavian artery coverage, potentially leading to ischemic complications. The role of the left subclavian artery revascularization procedure to prevent ischemic complications remains controversial. Therefore, we conducted a systematic review and meta-analysis to identify ischemic outcomes in patients who underwent thoracic Endovascular Aortic Repair with or without left subclavian artery revascularization. METHODS: A systematic search through electronic databases, including PubMed, Ovid Medline, and Cochrane, was conducted to identify relevant studies. The outcome parameters were left arm ischemia, stroke, and spinal cord ischemia. Risk ratio (RR) and Confidence Interval (CI) of 95% were measured and reported. RESULTS: A total of 11,386 patients were identified from 22 studies. Patients who underwent left subclavian artery revascularization had lower risk of left arm ischemia (RR 0.25, 95% CI 0.09-0.68; P = 0.0006; I2 = 71%), lower risk of stroke (RR 0.52, 95% CI 0.30-0.88; P = 0.02; I2 = 70%), and lower risk of spinal cord ischemia (odds ratio OR 0.72, 95% CI 0.55-0.95; P = 0.02; I2 = 0%) between the 2 groups. CONCLUSIONS: Revascularization procedure in patients with left subclavian artery coverage during thoracic Endovascular Aortic Repair is associated with a lower risk of left arm ischemia, stroke, and spinal cord ischemia. Left subclavian artery revascularization should be performed in anatomically high-risk patients. High-quality studies are needed to validate the outcomes.

Late presentation of middle aortic syndrome complicated with severe aortic regurgitation; the role of endovascular intervention as a bridging for Bentall surgery.

Middle aortic syndrome presents with segment narrowing of the descending thoracic and abdominal aorta. A common manifestation is uncontrolled hypertension, which can lead to severe aortic regurgitation in the long term. We have presented the case of a 31-year-old woman with worsening heart failure symptoms and longstanding uncontrolled hypertension. Echocardiography revealed severe aortic regurgitation. Aortic computed tomography showed severe stenosis of the aorta at the diaphragm level. Stent graft implantation was performed, followed by Bentall surgery 1 year later. Endovascular stent graft implantation of the descending aorta can be used safely as a bridging surgery for the Bentall procedure to reduce the patient's blood pressure and relieve heart failure symptoms.

Looping wire technique to facilitate true lumen wiring during TEVAR in type B aortic dissection with aneurysmal degeneration: A case report.

INTRODUCTION AND IMPORTANCE: Wiring true lumen during Thoracic Endovascular Aortic Repair (TEVAR) is sometimes difficult in complicated Type B Aortic Dissection (TBAD). CASE PRESENTATION: We treated a TBAD patient with large false lumen, compressed true lumen and multiple entries. After repeated wire misdirection to false lumen, we tried a new technique in which the wire in the false lumen was looped after entrance to true lumen and pushed distally. The looped wire was then used as guide to advance a second wire to the ascending aorta. TEVAR could then be completed with good result. DISCUSSION: Wiring the true lumen might be one of the most challenging steps during TEVAR in complicated TBAD. Several methods have been used to overcome the problems, but the cost and availability might be a problem in some countries. The looping wire technique may serve as an alternative method of guiding the process of wiring the true lumen during complicated TEVAR. CONCLUSION: Looping wire technique can be used as an alternative method to facilitate true lumen wiring during TEVAR.