One size does not fit all – Staged hybrid approach of a challenging aortic arch aneurysm using a double-branch custom-made device
DOI:
https://doi.org/10.48750/acv.689Keywords:
Endovascular Aneurysm Repair (MeSH), Branched TEVAR, Hybrid procedures, Aortic Aneurysm, Thoracic (MeSH), Stroke (MeSH)Abstract
Background: The anatomical complexity of the aortic arch poses significant challenges to its repair, particularly in high-risk patients. The introduction of branched endografts, specifically designed to overcome these challenges, has revolutionized this field as demonstrated in the present case-report.
Report: A 60-year-old male, with a prior history of smoking and neurosyphilis, was referenced to our outpatient clinic due to a CT finding of a 66mm aortic arch aneurysm with complex anatomical features, including a short brachiocephalic trunk and narrow iliac arteries. Thus, a staged hybrid approach was meticulously planned. The patient was initially submitted to a left carotid-subclavian bypass, followed by a right subclavian-carotid bypass. Later, an endoconduit was constructed using two GORE-Viabahn® stent grafts (11x100mm), deployed in the left common and external iliac arteries, facilitating subsequent TEVAR. Finally, the aneurysm was excluded using a custom-made Terumo-Relay® double inner-branched endograft (46x32x270mm) deployed in zone 0, with two inner branches for the brachiocephalic trunk (BCT)/right subclavian artery (RSA) and left common carotid artery (LCCA). The inner branches were catheterized via trans-carotid (left) and trans-axillary (right) accesses. An iliac extension GORE-Excluder® (16x12x100mm) to the BCT/RSA and a GORE-Viabahn® stent graft (7x75mm) to the LCCA were deployed. An additional extension endograft (34x30x150mm) was deployed to complete distal exclusion. The left subclavian artery was subsequently occluded using a vascular plug. Postoperatively, the patient experienced a minor posterior circulation stroke, with full recovery within two weeks. Six-month follow-up imaging showed patency of the endografts with complete exclusion of the aneurysm and no evidence of endoleaks. The patient remained asymptomatic, with no further vascular or neurological events.
Conclusion: This case highlights the feasibility of a staged hybrid approach for complex aortic arch aneurysms in patients with challenging anatomy. The use of a custom-made endograft and careful preoperative planning proved critical to the success of the procedure.
Downloads
References
Czerny M, Schmidli J, Adler S, van den Berg JC, Bertoglio L, Carrel T, et al. Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS). Eur J Cardiothorac Surg. 2019;55:133-62.
Brown JA, Arnaoutakis GJ, Szeto WY, Serna-Gallegos D, Sultan I. Endovascular repair of the aortic arch: State of the art. J Card Surg. 2021;36:4292-300.
Spath P, Campana F, Tsilimparis N, Gallitto E, Pini R, Faggioli G, et al. Outcomes of Fenestrated and Branched Endografts for Partial and Total Endovascular Repair of the Aortic Arch - A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg. 2024;67:106-16.
Ahmad W, Wegner M, Dorweiler B. Meta-analysis and meta-regression of the total endovascular aortic repair in aortic arch. Vasa. 2023;52:175-85.
Spear R, Haulon S, Ohki T, Tsilimparis N, Kanaoka Y, Milne CP, et al. Editor's Choice - Subsequent Results for Arch Aneurysm Repair with Inner Branched Endografts. Eur J Vasc Endovasc Surg. 2016;51:380-5.
Tsilimparis N, Detter C, Law Y, Rohlffs F, Heidemann F, Brickwedel J, et al. Single-center experience with an inner branched arch endograft. J Vasc Surg. 2019;69:977-85.
Tenorio ER, Oderich GS, Kolbel T, Dias NV, Sonesson B, Karelis A, et al. Multicenter global early feasibility study to evaluate total endovascular arch repair using three-vessel inner branch stent-grafts for aneurysms and dissections. J Vasc Surg. 2021;74:1055-65.
Czerny M, Berger T, Kondov S, Siepe M, Saint Lebes B, Mokrane F, et al. Results of endovascular aortic arch repair using the Relay Branch system. Eur J Cardiothorac Surg. 2021;60:662-8.
