Acute Aortic Dissection with Subacute Mesenteric Ischemia

2. Shang Loh, MD, FACS Associate Professor of Surgery Associate Directory – Aortic Center Division of Vascular Surgery Stony Brook University Medical Center Acute Aortic Dissection with Subacute Mesenteric Ischemia Division of Vascular Surgery

3. 41 y/o male presented with uncontrolled hypertension and an acute Type B aortic dissection with multiple high risk criteria for future aortic degeneration. The initial tear was in the proximal descending thoracic aorta with dissection extension into the SMA causing a high grade stenosis and a left renal fed off of the false lumen. Blood pressure was controlled and patient was asymptomatic thus semi-elective aortic stent grafting was planned for during the sub-acute phase. Prior to presenting for stent grafting, the patient also began experiencing post-prandial pain suggesting an element of mesenteric ischemia. History & Physical

4. • Aortic diameter > 40 mm • False lumen > 22 mm • Single entry tear > 10 mm • Patent false lumen • Round false lumen with elliptical true lumen shapes Pre-Op CTA True Lumen SMA Stenosis 4.6 cm False Lumen Left Renal

5. Bilateral percutaneous CFA access IVUS navigation through true lumen Deployment of two Cook Alpha (30x109 mm and 32x109 mm) thoracic endografts distal to the left subclavian across the entry tear. Repeat IVUS to ensure no areas of luminal compromise Selective catheterization of the SMA with stenting into aortic true lumen using a Gore VBX (7x19 mm) covered stent graft. Selective catheterization of the left renal through the dissection flap and false lumen with stenting back into aortic true lumen using a Gore VBX (5x27 mm) and Atrium iCast (5x22 mm) covered stent grafts. Operative Case

6. Intra-op Images SMA Stent True Lumen L Renal Stent False Lumen

7. Post CTA Positive aortic remodeling with false lumen thrombosis and true lumen re-expansion. Patent left renal stent with false lumen flow retrograde stopping at the stent. Patent SMA stent Patent left renal into aortic true lumen and patent SMA stent.

8. Dr. Loh completed his undergraduate training at the University of California at Berkeley and medical school at Texas A&M University. During medical school he spent a year at Stanford University studying the effect of glucose on endothelial cell function. He performed his general surgery residency at New York University Medical Center in Manhattan during which he spent an additional two years at Stanford University as a post-doctoral research fellow studying the role of endothelial progenitor cells in vessel formation and wound healing. Following this, he went on to complete a fellowship in vascular surgery again at NYU Medical Center. He subsequently joined the faculty at Stony Brook University Medical Center where he is currently an Associate Professor of Clinical Surgery. He is also the Program Director for the Vascular Surgery Residency and Fellowship programs and Associate Director for the Stony Brook Aortic Center. His main area of interest is in endovascular treatment of aortic dissection and complex endovascular aortic interventions. Shang Loh, MD FACS Commentary Dr. Nicos Labropoulos, Director of ScIENCE Dr. Loh has great experience in the endovascular management of aortic disease. Being the program Director in our training program in Vascular Surgery has a major interest in the education of Vascular trainees. He is very Interactive and to the point, explaining facts in a simple manner.