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Figure 9.4. The scan is from a 58-year-old man with an acute type B dissection. As shown, the left kidney has no perfusion, and the left renal artery comes off the false lumen. Also, the perfusion of the right kidney is marginal due to the scant perfusion of the right renal artery. The right kidney was saved by auto transplantation.

Figure 9.4. The scan is from a 58-year-old man with an acute type B dissection. As shown, the left kidney has no perfusion, and the left renal artery comes off the false lumen. Also, the perfusion of the right kidney is marginal due to the scant perfusion of the right renal artery. The right kidney was saved by auto transplantation.

and adding a surgical trauma to their extreme situation will probably be disastrous to many patients in the future. A possible alternative approach would be to treat these patients in a modern radiology/OR suite with two primary aims: to rapidly determine the major pathological aortic segment using precise and rapid imaging techniques and attack this pathology using percutaneous techniques aimed at the defects only in an attempt to do a rescue procedure alone. Such an approach will depend heavily on physicians with precise clinical understanding of these patients who also can master the diagnostics and intervention radiology techniques to rapidly reverse an almost lost situation.

What can be done in the radiology or interventional surgery suite with these patients? First and foremost, they demand a team with determined anesthesiologists, cardiologists, radiologists, surgeons, or physicians with particular skills in handling these complex patients. Important points to address will be to close the sites of entry and/or rupture with covered stent grafts concomitant with ongoing resuscitation and handling of an acute tamponade or occluded coronary arteries. Probably the most challenging will be to rapidly address cerebral, spinal, and renal malperfusions. Figure 9.4 illustrates the use of such combined procedures. This 58-year-old man presented with gross malperfusion of his kidneys and an almost occluded true lumen from an expanding false lumen. A stent graft was immediately placed over the primary entry site to expand the

Figure 9.5. Complete debranching of the aortic arch covered by stent graft for arch aneurism and intrathoracic bypass between ascending aorta, innominate artery, and left common carotid artery.

true lumen and therefore improve the intestinal perfusion. The left kidney was reperfused by fenestration but was permanently damaged from long-standing complete ischemia. In the ensuing weeks, the function of the right kidney was marginal, and after 3 weeks, the kidney was auto transplanted into the pelvis with subsequent normalization of kidney function.

Treating a destroyed aortic valve with percutaneous techniques will also be a demanding task. However, it can be envisioned in a foreseeable future.

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