Soru

A 67-year-old man is evaluated in the emergency department for sudden-onset, severe, tearing pain between his shoulder blades that began two hours ago. He has a history of poorly controlled hypertension, hyperlipidemia, and a 40-pack-year smoking history. On presentation, his blood pressure is 218/114 mmHg in the right arm and 212/110 mmHg in the left arm, and his heart rate is 112/min. Physical examination reveals a distressed, diaphoretic patient. Cardiovascular examination shows a regular rhythm with no murmurs. Abdominal examination reveals diffuse tenderness with voluntary guarding and diminished bowel sounds. The right lower extremity is cool to the touch with absent dorsalis pedis and posterior tibial pulses; left lower extremity pulses are normal. Initial laboratory studies show a serum lactate level of 5.8 mmol/L and a serum creatinine of 2.1 mg/dL (baseline 1.0 mg/dL). Intravenous esmolol and nicardipine infusions are initiated, successfully lowering his blood pressure to 118/74 mmHg and heart rate to 62/min. A computed tomography angiography of the chest, abdomen, and pelvis demonstrates an intimal flap originating just distal to the left subclavian artery and extending into the common iliac arteries. The true lumen is severely compressed by the false lumen. The superior mesenteric and right renal arteries arise from the false lumen, which exhibits delayed and sluggish contrast enhancement. Which of the following is the most appropriate next step in the management of this patient?