A Case of Type B Aortic Dissection: The Role of Transesophageal Ultrasound Guidance in Thoracic Endovascular Aortic Repair.

ABSTRACT

Thoracic endovascular aortic repair (TEVAR) plays a central role in managing acute and chronic aortic pathologies. With the advancement of transcatheter structural heart procedures, echocardiography has become a key in procedural guidance. Despite consensus on its use for cardiac interventions, ultrasound assistance in aortic procedures is not widely standardized. A 71-year-old obese man with chronic type B aortic dissection underwent a TEVAR procedure, using a single-branched aortic stent graft (Endovastec™ Castor™) and with transesophageal ultrasound guidance. The preprocedural assessment confirmed the presence of aortic dissection of the descending thoracic aorta with a posterior true lumen (TL) and an anterior false lumen (FL), normal aortic valve anatomy and function, normal left ventricular function, absence of intracavity thrombus, and absence of aortic plaques that could prevent the optimal implantation of the stent graft. During the procedure, a transesophageal echocardiogram (TEE) monitored the positioning of the guide wires, the arrival of the catheter of the thoracic endoprosthesis, and then the implantation of this at the level of the aortic arch and the descending thoracic aorta. Postprocedure TEE evaluation underlined full stent-graft deployment without leaks and successful exclusion of FL with the beginning of thrombosis. Angiography confirms the exclusion of the aneurysm and the absence of endoleaks. This clinical case demonstrates how transesophageal echocardiographic guidance can improve the TEVAR procedure by minimizing fluoroscopy time, contrast medium use, and enabling a better assessment of the dissection anatomy with real-time monitoring of both the TL and the FL. In conclusion, TEE can serve as an auxiliary intraoperative imaging tool to provide good information before, during, and after the procedure, increasing the success and safety of the TEVAR.