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Jeffrey Jim, MD, Luis A. Sanchez, MD, Brian G. Rubin, MD.
Washington University School of Medicine, St Louis, MO, USA.
Objective: While TEVAR has become a widely accepted modality to treat aortic diseases, certain anatomic characteristics limit its applicability. As we expand the use of this technique, branched endografts are novel devices which can treat patients with prohibitive risk for traditional open surgery. We report a case of a branched TEVAR to salvage an aorto-renal bypass originating off a thoracic aortic patch aneurysm following a previous open thoracoabdominal aortic aneurysm repair.
Methods: A 72 year old male presented with thoracic pain. Eight years ago, a descending aortic dissection and aneurysm were treated with thoracoabdominal aortic graft placement and visceral and intercostal patch reimplantation. A separate left aorto-renal bypass was performed with the bypass originating from the thoracic portion of the graft. He now presents with a 7.2cm descending aortic patch aneurysm across from the origin of the patent aorto-renal bypass. His baseline creatinine is <1.0mg/dl.
Results: A branched endograft was fashioned using a Cook TX2 device and a 7mm Viabahn stent-graft anastomosed to a fenestration created in the body of the endograft. The modified device was delivered successfully into the thoracic aorta. The Viabahn branch was cannulated from the left arm and a Fluency stent was delivered to bridge the gap and recreate the aorto-renal bypass. A completion angiogram demonstrated aneurysm exclusion and flow through the aorto-renal bypass. There were no intraoperative complications and his postoperative course was unremarkable. His serum creatinine remained <1.0mg/dl. A post-procedure CT scan demonstrated an excellent technical result.
Conclusions: The use of a surgeon-modified branched thoracic endograft is technically challenging. In selected cases, this technique can be used for successful aneurysm exclusion while maintaining patency of critical branch vessels. Until branched endografts become commercially available, surgeons may consider the use of modified devices for anatomically suitable patients that are not candidates for other treatment alternatives.
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