Aortic Dissection Flap Fenestrations

Aortic dissection is a life-threatening condition characterized by a tear in the innermost layer of the aorta (tunica intima), permitting blood to enter and separate the intima from the aorta’s middle layer (tunica media). This event creates a false lumen (FL) alongside the true lumen (TL) of the aorta.

Typically, the FL is larger with less flow/pressure than the TL; however, additional tears in the aorta can permit the re-entry of blood into the FL. Additionally, fenestrations in the dissection flap create communications between the TL and FL, predisposing the patient to rupture or malperfusion.

This transesophageal echocardiography (TEE) view of the descending thoracic aorta (DTA) shows a prominent dissection flap with spontaneous echo contrast, a sign of sluggish blood flow, in the FL. An organized thrombus is visualized distally. Color-flow Doppler shows several fenestrations (white arrows) within the dissection flap with flow directed from the TL to the FL as expected. A large fenestration is seen at the distal arch/proximal DTA.

Management options vary based on the location of the dissection and patient comorbidities but can range from open surgical repair (typically for ascending dissections), endovascular techniques (stent grafts can be deployed to cover the primary tear and fenestrations thereby stabilizing the dissection flap), or medical management in stable DTA dissections

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