Endovascular Approach to Visceral Patch Pseudoaneurysm Following Thoracoabdominal Aortic Aneurysm Repair
Philip M. Batista, MD, Julia Glaser, MD, Daniel H. Newton, MD, Paul J. Foley, MD.
Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
OBJECTIVES: The management of subsequent aortic pathology following complex aortic repairs can be a great challenge, especially in an aging population burdened with comorbities. We present a case of a visceral patch pseudoaneurysm from a previous Extent III thoracoabdominal aneurysm repair and our approach to an endovascular treatment.
METHODS: The patient is a 72-year-old male, who in 2001 underwent elective open repair of an infrarenal abdominal aortic aneurysm with a bifurcated aortoiliac graft via a midline laparotomy. He then presented in 2005 with acute onset of severe back pain and was found to have aneurysmal degeneration and contained rupture of the visceral aorta along with the proximal suture line of his graft. He underwent an emergent Extent III thoracoabdominal aneurysm repair. The reconstruction was achieved using a Dacron graft with a side-side sewn on visceral patch consisting of the celiac artery, superior mesenteric artery and the right renal artery. The left renal artery was reimplanted in an end-end fashion to a Dacron side branch. He recovered well and was lost to follow-up several years later. He returns in 2017 after obtaining a screening CT scan which demonstrates a 6.4cm pseudoaneurysm of the aorta at the level of the visceral arteries (figure 1). Also, his left renal artery graft had thrombosed resulting in some mild renal insufficiency. Of note, his past medical history is significant for obesity, COPD, sleep apnea, and multiple laparotomies including ventral hernia repair with mesh. Given all these factors, we proceeded with an endovascular approach to repairing his pseudoaneurysm.
RESULTS: We were able to successfully snorkel the celiac and superior mesenteric arteries, periscope the right renal artery, and exclude the pseudoaneurysm using an Endologix AFX stent graft. Follow-up imaging at one month demonstrated stable sack size with no signs of endoleak and patent stents.
CONCLUSIONS: Endovascular repairs of complex aortic pathology can be safe and viable options, especially in ill patients with multiple previous open operations. 
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