title: Cheese wire fenestration of a chronic juxtarenal dissection flap to facilitate proximal neck fixation during EVAR.
abstract: BACKGROUND
  To describe successful endovascular repair of a complex chronic aortoiliac dissection facilitated by a unique endovascular fenestration technique at the proximal neck.
  
  
  METHODS
  A 57-year-old man presented with disabling lower extremity claudication and a remote history of medically treated type B aortic dissection. Computed tomographic angiography demonstrated a complex dissection with 7.1-cm false lumen aneurysmal dilatation and significant true lumen compression within bilateral iliac aneurysms and no suitable proximal infrarenal neck free of dissection.
  
  
  RESULTS
  Using intravascular ultrasound, guidewires were introduced into true and false lumens. A 9F sheath was placed on the right side, and a 20-ga Chiba needle was positioned at the level of the celiac artery and oriented toward the dissection flap. The needle was advanced to puncture the flap, and a 0.014-in wire was then snared from the true to the false lumen. Shearing of the dissection flap in the juxtarenal segment was performed using a "cheese wire" technique, whereby both ends of the guidewire were pulled caudally in a sawing motion down through the infrarenal neck and into the aneurysm sac. Angiography confirmed absence of residual dissection and perfusion of the visceral vessels via the true lumen. Given the newly created infrarenal neck, standard endovascular aortic repair (EVAR) was performed and antegrade and retrograde false lumen flow was obliterated from the visceral vessels. Postoperative imaging confirmed aneurysm exclusion, no endoleak, and patent bilateral common iliac arteries with resolution of claudication symptoms and normal ankle-brachial indices.
  
  
  CONCLUSIONS
  Endovascular management of false lumen aneurysms in the setting of chronic dissection is limited by the ability of stent grafts to obtain adequate proximal or distal fixation. Endovascular fenestration of these chronic flaps facilitates generation of suitable landing zones, thereby serving as a useful adjunct to standard EVAR.
authors.affiliation: Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA.
authors.forename: Brant W
authors.initials: BW
authors.lastname: Ullery
authors.affiliation: Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA.
authors.forename: Venita
authors.initials: V
authors.lastname: Chandra
authors.affiliation: Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA.
authors.forename: Michael
authors.initials: M
authors.lastname: Dake
authors.affiliation: Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA. Electronic address: jtlee@stanford.edu.
authors.forename: Jason T
authors.initials: JT
authors.lastname: Lee
mesh_terms: D000784:Aortic Dissection / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation / Q000379:methods*; D002908:Chronic Disease; D057510:Endovascular Procedures / Q000295:instrumentation / Q000379:methods*; D006439:Hemodynamics; D006801:Humans; D017543:Iliac Aneurysm / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D007383:Intermittent Claudication / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D015641:Radiography, Interventional; D015607:Stents; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional