Complications of Endovascular Septal Fenestration in the Management of Patients With Aortic Dissection

In cases of complicated aortic dissection, critical branch vessels in the abdomen may be compromised with resulting clinically important organ ischemia. In some cases, the cause of the branch vessel involvement and associated malperfusion may be a dynamic aortic phenomenon that severely narrows the true lumen and places the dissection septum over the affected branch arteries obstructing their inflow like a curtain. Endovascular techniques including balloon-mediated and guidewire-mediated septectomy may be used to disrupt the septum and relieve the branch vessel malperfusion. These procedures involve multiple steps and complex endovascular maneuvers. As such, endovascular septectomy may not be appropriate in certain cases with highly tortuous anatomy or complicated septal morphology. In addition, complications from inadvertent needle puncture of the outer wall of the aorta, unpredictable shearing, shifting, or embolization of septal tissue may exacerbate malperfusion and potentially create irreversible ischemia by leading to obstruction not amenable to endovascular management. Fortunately, most complications associated with endovascular septectomy procedures can be managed successfully by endovascular bail-out techniques without permanent sequelae.