Catheter-directed thrombolytic therapy of acutely thrombosed and dissected visceral arteries has been reported, with mixed results. Secondary procedures, including stenting [61] and laparotomy [2, 62], are frequently needed. Most success with catheter-directed thrombolysis (CDT) was achieved in patients with renal artery thrombosis due to dissection [42–44, 56]. In cases of RAD with acute renal artery thrombosis, CDT using urokinase [42, 43] and tissue plasminogen activator (rt-PA) [44], or combined with aspiration thrombectomy under antithrombotic protection with glycoprotein IIb/IIIa inhibitor [56], has been used successfully before stent placement in hemodynamically stable patients and achieved good early results.

Sufficient collateral flow is essential to avoid organ infarction if we use embolization for IVAD to occlude visceral arteries. Successful embolizations of renal and celiac artery dissections have been reported [63]. Takeda et al. [60] reported on treatment of CAD with coils. Platinum-fiber coils (Cook Medical) and detachable Amplatzer Vascular Plugs (AVPs) I, II, and/or IV (AGA Medical, Golden Valley, MN, USA) were embolization materials used. Perini et al. recommend that the diameter of the AVPs is approximately 30–50 % larger than that of the treated artery [45].

Li et al. suggested coil embolization to occlude the false lumen and stent placement to improve flow through the true lumen in patients with type V SMAD [25]. However, the need for coil embolization in such patients has been questioned since placement of self-expandable stent will reduce the aneurysm size with gradual resolution of the false lumen and the increase in diameter of the true lumen [34, 38, 64, 65].

At present, there are no evidence-based data that support the choice of the best type of stent for each specific IVAD. For principles of visceral artery stenting and the use of balloon or self-expandable stents, or covered or bare metal or nitinol stents, the readers should consult Chaps. 13, 14, and 18. Precise positioning and good flexibility are requirements for the stent used in the treatment of IVAD. Careful planning includes selection of the length of the stent that can be deployed at the location, the size of entry and reentry sites, measurement of the length of the broad-based pseudoaneurysm, and the severity of arterial stenosis [16] (Fig. 32.3).

Because of the radial strength, conformability, and sufficient length, self-expandable stents are recommended in the management of IVAD. Numerous stents such as WALLSTENT (Boston Scientific, Natick, MA), Zilver or Zilver 635® stent (Cook Medical, Bloomington, IN), SMART or PRECISE stent (Cordis, Miami Lakes, FL), Palmaz Blue stent (Cordis, Bridgewater, NJ), Xpert (Abbott Vascular, Abbott Park, IL), Astron Pulsar (Biotronik AG, Switzerland) have been used with diameters of up to 8 mm and overall lengths of up to 100 mm. Stents with a diameter 10 % greater than the diameter of the proximal artery are usually chosen [5, 16, 25, 31, 35, 58, 60, 66–68]. Sinus-SuperFlex nitinol stent (OptiMed, Ettlingen, Germany) was used with success by one group for RAD [56]. For short dissection, a balloon-expandable stent can be considered [33, 60]. However, the balloon-expandable stent is stiffer and the resulting axial force is greater so it should be avoided in the curved, second segment of SMA. Although covered stent was reported to treat a ruptured SMAD [26], a potential disadvantage is that it obliterates side branches of the treated artery. Covered stent, however, was also used with success to treat SMAD [69, 70].

Occasionally, laparotomy can be combined with transmesenteric endovascular approach and retrograde mesenteric stenting (hybrid treatment) [15, 49]. Intravascular ultrasound (IVUS) may be helpful to identify the true and false lumen, image the flap, and even establish the site of the tear in the artery.

The double-coaxial technique (mother-and-child technique) might be helpful to facilitate the delivery of stent to a complex lesion [71]. In patient with large discrepancy in diameters between proximal and distal arteries, two stents of different calibers with an overlap of 1.5 cm were suggested [14]. Chu et al. pointed out that in long dissection, coverage of a short segment at the entry tear by the stent graft or even bare stent can yield good result with gradual resolution of the mural hematoma on follow-up CTA images [16].

Currently, endovascular treatment with stenting is increasingly used in patients with RAD [43, 44, 56]. The risk of acute occlusion after stent placement, however, must be weighed in each case. Considering the lesion needs to be completely covered, long stents are frequently needed; however, long stents are more thrombogenic than short stents. Thus, stent thrombosis is also a concern. When the dissection extends into the renal hilum, the risk of renal infarct and further extension of the dissection with placement of a stent is high [56].