True-lumen collapse of downstream aorta can occur despite entry exclusion after open surgery for type A aortic dissection. We report a patient with severe intermittent claudication due to true-lumen collapse at the level of the inrarenal aorta, treated successfully with fenestration and custom-made abdominal aortic stent graft.

A 51-year-old male patient without comorbidities was admitted to the emergency room for chest pain. A CT-angiogram revealed an type A aortic dissection with a dissection membrane extending to the right common iliac artery. The patient was immediately operated with replacement of the aortic root, ascending aorta and hemiarch. The postoperative CT-angiogram demonstrated a true-lumen collapse in the thoraco-abdominal aorta and the patient complained of claudication in the right lower limb and buttock. An endovascular fenestration of the dissection membrane at the level of the infrarenal aorta (Figure 1) followed with nearby complete disappearance of his symptoms. Four months after discharge the patient experienced similar symptoms with claudication in both legs and buttocks. New CT-angiogram showed similar morphology of the dissected aorta with patent infrarenal fenestration and without clear explanation for the claudication. We presumed that the movement of the dissection membrane at the level of the infrarenal aorta influences the true lumen perfusion of both common iliac arteries, this limiting the blood flow in both legs. We decided to treat the patient with a custom-made bifurcated abdominal aortic stent graft (short main body without struts) seven months after index operation. The main body was placed at the level of the infrarenal fenestration with limb extensions in both common iliac arteries (Figure 2). Thus, the dissection membrane was completely excluded at the level of the infrarenal aorta and the stent graft was perfused from both lumina proximally. The postoperative course was uneventful and the patient experienced no more claudication. He was discharged on postoperative day 2.

Treatment of lower limb claudication after aortic dissection could be challenging. Threating strategy must be adapted individually according to the type of dissection, location and configuration of the dissection membrane. Custom-made endovascular solution might give an alternative to open surgery.