Case Report: staged segment-specific open and endovascular treatment of chronic post-dissection aortic disease with descending thoracic and giant infrarenal aneurysmal components

Azat Chinaliyev, Mukhammejan Orazbay, Gulinur Chinaliyeva, Didar Khassenov, Tokan Sultanaliyev, Irlan Sagandykov, Aktolkyn Daumen

Frontiers in Cardiovascular Medicine, 2026

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DOI 10.3389/fcvm.2026.1925462
Data confidence 70 medium
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Abstract

Background Contemporary management of chronic post-dissection aortic disease includes open repair, thoracic endovascular aortic repair (TEVAR) with or without adjunctive false-lumen occlusion, fenestrated/branched endovascular repair, and staged open-endovascular strategies. Selection depends on anatomy, rupture risk, malperfusion, physiological reserve, and device availability. Case presentation A 56-year-old woman with body mass index 47.2 kg/m 2 and major cardiometabolic comorbidity presented with progressive abdominal pulsation. CTA demonstrated chronic Stanford type B/DeBakey III dissection with descending thoracic aneurysmal degeneration to 52.7 mm, a dominant symptomatic infrarenal aneurysmal component measuring approximately 11–12 cm, bilateral common iliac involvement, and residual paravisceral dissection without treatment-triggering enlargement or malperfusion. No Crawford extent was assigned because complete longitudinal centerline imaging was unavailable. Stage I comprised transperitoneal open aorto-bi-iliac reconstruction. After 118 days, elective morphology-driven zone 2 TEVAR was performed to cover the reported proximal entry region and reduce antegrade false-lumen inflow. Intentional left subclavian artery (LSA) coverage without prophylactic revascularization was followed by symptomatic subclavian steal requiring unplanned carotid-subclavian bypass. Results No perioperative death, stroke, spinal cord ischemia, bowel ischemia, myocardial infarction, acute kidney injury, graft thrombosis, prosthetic infection, or access complication occurred. At latest follow-up, the patient was asymptomatic and all reconstructions were patent. Conclusion This case illustrates competing priorities in segment-specific management of chronic post-dissection aortic disease. The unequivocal indication for urgent infrarenal repair contrasted with discretionary pre-emptive thoracic intervention below the conventional diameter threshold. The LSA-related complication emphasizes prophylactic LSA preservation/revascularization, spinal collateral planning, and lifelong surveillance of the untreated paravisceral segment after previous abdominal aortic reconstruction.