The patient is a 66-year-old male with stage IV chronic kidney disease (CKD) who was admitted with right sided chest pain and transient hypotension which resolved with fluid resuscitation on arrival. Computed tomography angiography (CTA) was performed immediately and revealed a 5 cm aneurysm confined to proximal descending thoracic aorta with evidence of contained rupture. It also demonstrated the presence of an acute type B thoracic aortic dissection (TBAD) and a right-sided aortic arch. The dissection began just distal to the right common carotid artery and involved the origin of the left subclavian artery (SCA). The left common carotid artery arose proximally on the arch and was uninvolved (Fig. 1).
Using a totally percutaneous approach, a 37 mm by 20 cm long conformable Gore  TAG  thoracic endoprosthesis (Flagstaff, Arizona) was placed in proximal descending thoracic aorta covering the left SCA (Fig. 2). A chest tube was inserted to evacuate the right hemothorax. Aside from the institution of hemodialysis due to progression of his pre-existing CKD, the patient had an uneventful recovery. CTA one-month post-procedure revealed a type IB endoleak due to degeneration of the distal descending thoracic aorta. To exclude the endoleak, the repair was extended distally using a repeat percutaneous approach and a 38 mm by 107 mm long Medtronic Valiant  thoracic stent graft (Minneapolis, Minnesota) (Fig. 3). Six months later, the left subclavian artery was coil embolized to treat an additional retrograde (Type II) endoleak (Fig. 4). The patient has done well with no further evidence of endoleak or aneurysm expansion (Fig. 5). Autologous dialysis access was created in his right upper extremity.
Emergency treatment of complex aortic pathology is challenging in the setting of a right-sided aortic arch. CTA, along with post-processing reconstructions, is always helpful. Initial limited stent graft coverage of the thoracic aortic pathology seemed very appropriate until the follow-up CTA revealed a Type IB endoleak. While the endoleak prompted additional intervention, the end result was excellent. This case displays the importance of careful attention to detail and close follow-up in these complicated patients. Please note this case report follows the CARE guidelines and has also been reported in line with the SCARE criteria. The patient has given informed consent for publication of this case report and the Geisinger IRB has approved case presentations.