# Complex Management of Extensive Stanford Type B Aortic Dissection With Multiorgan Failure and Acute Limb Ischemia Treated by Femoro-Femoral Bypass and Complicated by Iatrogenic Brachial Arteriovenous Fistula: A Case Report

## TL;DR

A 62-year-old woman with severe aortic dissection and limb ischemia underwent complex surgical treatments and later developed an iatrogenic arteriovenous fistula.

## Contribution

This case highlights the challenges of managing complicated type B aortic dissection with delayed iatrogenic complications.

## Key findings

- Femoro-femoral bypass was effective in saving the patient's limb during acute ischemia.
- TEVAR successfully repaired the aortic dissection after multiorgan complications were managed.
- An iatrogenic brachial arteriovenous fistula was surgically excised with full arterial preservation.

## Abstract

We present the case of a 62-year-old woman with a history of long-standing, poorly controlled arterial hypertension, with average home blood pressure readings of approximately 140-160/100-110 mmHg despite treatment with ramipril, who was urgently admitted due to acute critical ischemia of the left lower limb. Imaging revealed an extensive Stanford type B aortic dissection (TBAD) involving the thoracoabdominal aorta and iliac arteries, with significantly impaired perfusion of the left leg. Due to the severity of limb ischemia and limitations to immediate endovascular repair, an urgent right-to-left femoro-femoral bypass was performed as a limb-saving procedure. Postoperatively, the patient developed multiorgan complications, including acute kidney injury (AKI) requiring hemodialysis and bowel ischemia, which were managed conservatively. The definitive repair of the dissection was achieved through thoracic endovascular aortic repair (TEVAR). Several weeks later, the patient presented with a gradually enlarging, painless, pulsatile mass in the right antecubital fossa, corresponding to a prior arterial access site. Clinical features, including a palpable thrill and audible bruit, were consistent with an iatrogenic arteriovenous fistula (AVF), which was surgically excised with the preservation of arterial flow and uneventful recovery. This case underscores the complex and life-threatening course of complicated type B aortic dissection with peripheral malperfusion, the necessity of staged hybrid management, and the importance of long-term follow-up for detecting delayed iatrogenic complications associated with endovascular procedures.