A 45-year-old man with severe, tearing chest pain was admitted to the emergency department. Computed tomography angiography (CTA) revealed a Stanford type A aortic dissection, with the primary entry tear located at the origin of the left subclavian artery. The patient underwent total arch replacement combined with a frozen elephant trunk (FET) procedure.

On postoperative day 1, the patient was successfully extubated in the intensive care unit. However, blood tests revealed a lactate value of 7.4, accompanied by hepatic and renal insufficiency, indicating severe renal and liver malperfusion. Urgent CTA demonstrated the accidental rupture of the FET graft into the false lumen (FL), resulting in compression of the true lumen (TL) (figure 1A).

Figure 1

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Emergent intima fenestration and thoracic endovascular aortic repair (TEVAR) were performed. Intraoperatively, it was found that the FET graft had penetrated the FL of the descending aorta, causing severe occlusion of the TL and involving the celiac trunk artery, superior mesenteric artery, and left renal artery (video 1 of the supplementary data). An atrial septal puncture needle was used to fenestrate the membrane into the TL (figure 1B; video 2 of the supplementary data), followed by the deployment of a thoracic endovascular stent graft (Endovastec, China) to cover the rupture caused by the FET graft. Angiography confirmed the restoration of intra-abdominal aortic blood flow (video 3 of the supplementary data). Postoperative CTA, performed 2 days after the procedure, indicated the successful reversal of organ malperfusion through the fenestrated TEVAR (figure 1C).