Angioscopy-assisted thoracic endovascular aortic repair for chronic type B aortic dissection - Optimizing stent graft coverage and left subclavian artery coil embolization

Sep 28, 2026

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A 69-year-old man with chronic type B aortic dissection and progressive aneurysmal enlargement underwent zone 2 TEVAR with a carotid-subclavian bypass. Nonobstructive general angioscopy identified additional tiny entry tears in the descending aorta, enabling adequate stent graft coverage. Balloon-occluded left subclavian coil embolization showed satisfactory fluoroscopic packing, while angioscopy detected residual flow through coil gaps, prompting further coil placement. Angioscopy confirmed blood flow cessation and completion angiography showed no antegrade false lumen flow or endoleaks. At 3 months, CT demonstrated favorable remodeling with complete thoracic false lumen thrombosis.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages5

Reading Time13 min

AccessFree to download

ABSTRACT

Keywords

Background

Case Report

Patient history and imaging

Procedure planning (zone 2 TEVAR)

NOGA assessment and stent graft coverage

Angioscopy findings and coil embolization endpoint

Angioscopy-assisted thoracic endovascular aortic repair for chronic type B aortic dissection: Optimizing stent graft coverage and left subclavian artery coil embolization Yukihisa Ogawa, MD, PhD, FJCR,a Hiroyuki Nishi, MD, PhD,b Hidekazu Furuya, MD,b Ryuichi Tamimoto, MD,b Satoru Takahashi, MD,c and Shunsuke Kamei, MD,a Hachioji and Osaka, Japan ABSTRACT We report the case of a 69-year-old man with chronic type B aortic dissection and progressive aneurysmal dilatation. Zone 2 thoracic endovascular aortic repair was performed with carotid-subclavian bypass. Nonobstructive generalangioscopy identified additional tiny entry tears in the descending aorta, guiding adequate stent graft coverage. Subsequent left subclavian artery coil embolization under balloon occlusion revealed satisfactory packing on fluoroscopy, but angioscopy revealed residual flow through coil gaps, prompting additional coil placement. Blood flow cessation was confirmed by angioscopy. Completion angiography revealed no antegrade false lumen flow or endoleaks. Follow-up computed tomography at 3 months showed favorable aortic remodeling with complete thoracic false lumen thrombosis. (J Vasc Surg Cases Innov Tech 2026;12:102058 . ) Keywords: Aortic remodeling; Coil embolization; Left subclavian artery; Nonobstructive general angioscopy; TEVAR Type B aortic dissection (TBAD) often extends immediately distal to the left subclavian artery (LSA), necessitating zone 2 thoracic endovascular aortic repair (TEVAR) with intentional coverage of the LSA. Nonobstructive general angioscopy (NOGA) has recently been reported to be a useful adjunct in TEVAR for TBAD.1 This is an intravascular endoscopic technique that enables direct, real-time visualization of minor entry tears and intimal surface irregularities that are difficult to identify on computed tomography (CT) under continuous saline flushing without interrupting blood flow. It facilitates appropriate stent graft coverage and promotes favorable aortic remodeling.1,2 Contemporary guidelines recommend routine LSA embolization with revascularization with zone 2 coverage to prevent endoleaks and spinal cord ischemia.3,4 Robust evidence specifically demonstrating undiagnosed endoleaks after LSA embolization is limited. Therefore, we have focused on the current case to From the Department of Radiology,a and Department of Cardiovascular Surgery,b Tokai University Hachioji Hospital, Hachioji; and the Department of Cardiology, Osaka Gyomeikan Hospital, Osaka.c Additional material for this article may be found online [at](at www.jvscit.org)[ www.jvscit.org](at www.jvscit.org). Correspondence: Yukihisa Ogawa, MD, PhD, FJCR, Department of Radiology, Tokai University Hachioji Hospital, 1838 Ishikawa-machi, Hachioji 1920032, Japan (e-mail: [ogawa.yukihisa.r@tokai.ac.jp](ogawa.yukihisa.r@tokai.ac.jp)) . The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 2468-4287 © 2025 The Author(s) . Published by Elsevier Inc. on behalf of Society for Vascular Surgery. This is an open access article under the CC BY license ([http://creativecommons.org/licenses/by/4.0/](http://creativecommons.org/licenses/by/4.0/)) . [https://doi.org/10.1016/j.jvscit.2025.102058](https://doi.org/10.1016/j.jvscit.2025.102058) highlight the potential of NOGA as a practical adjunct providing direct visualization beyond angiography. Here, we report a case of zone 2 TEVAR for chronic TBAD with false lumen expansion, in which NOGA was instrumental in identifying minor entry tears for stent graft coverage and in determining the endpoint of LSA coil embolization. CASE REPORT A 69-year-old male with a history of chronic TBAD diagnosed 7.5 years earlier, presented with aneurysmal dilatation (zone 3) that had progressed from 35 mm at onset to 53 mm on follow-up CT. H

FAQs

How did nonobstructive general angioscopy (NOGA) change the TEVAR plan in this case?

NOGA identified additional tiny entry tears in the descending aorta that were not seen on computed tomography, guiding sufficient stent graft coverage.

Why was additional coil placement needed after left subclavian artery embolization?

After balloon occlusion, fluoroscopy suggested satisfactory packing, but angioscopy showed residual flow through gaps between coils, leading to further coil placement.

What were the key outcomes during and after the procedure?

Angioscopy confirmed cessation of blood flow, completion angiography showed no antegrade false lumen flow or endoleaks, and 3-month CT showed complete thoracic false lumen thrombosis with favorable aortic remodeling.

Sep 28, 2026

Uploaded by Ezra