A 69 year old male with arterial hypertension and dyslipidaemia was admitted because due to sudden intense back pain. CTA confirmed TBAD with the primary entry tear located immediately distal to the left subclavian artery (LSA) and extending to the aortic bifurcation. Both the TL and the FL were patent, the TL was severely compressed by the FL and all the renal and visceral arteries emerged from the TL. Moreover, the arch had a bovine morphology and the left vertebral artery (LVA) took origin from the aortic arch.
The patient was managed conservatively and discharged under strict antihypertensive medication. Four months after the initial event he reported severe bilateral lower limb claudication which was attributed to the extreme compression of the TL by the FL in the visceral segment although no evidence of visceral malperfusion was present (Fig. 4). Additionally, the duplex scan evaluation revealed an 80% bilateral carotid stenosis.
The patient was admitted for a staged hybrid procedure with left carotid endarterectomy (CEA) associated with partial arch debranching consisting in re-implantation of the LVA into the CCA and left carotid-subclavian bypass with proximal ligation of the LSA.
One week after the first procedure, and after placement of a CSF drain, a STABILISE technique was performed, consisting of TL catheterisation with an extra stiff guidewire (Lunderquist ; Cook Medical ) and deployment of two stent grafts (ZTA  P-34-209 + ZTA  P-34-161, Cook Medical ) 3 cm above the celiac trunk. A Cook Medical Zenith Dissection Endovascular Stent  (ZDES  34-180) was then deployed over the visceral aorta and landing distally four cm below the renal arteries. Finally, a 46 mm Coda balloon (Cook Medical) was used to sequentially dilate (craniocaudal direction) the stent grafts and the dissection stent aiming to obliterate the FL (Fig. 5). The completion angiogram and the post-operative CTA confirmed the complete realignment of the aorta with TL patency, FL obliteration, and patency of all aortic branches (Figure 4, Figure 6).
There were no complications.