False Lumen Embolization to Manage Aneurysm Enlargement after TEVAR: A Growing Solution to a “Growing” Problem
Evan R. Brownie, MD, Jeffrey Jim, MD, MPHS.
Barnes-Jewish Hospital, St. Louis, MO, USA.
DEMOGRAPHICS: A 71-year-old male presents with an enlarging aneurysm sac due to distal false lumen perfusion after prior thoracic endovascular aortic repair (TEVAR).
HISTORY: He initially suffered an aortic dissection involving the left subclavian artery to the iliac bifurcation three years prior that was successfully medically managed. He then developed early aneurysmal degeneration of the thoracic aortic segment and underwent cervical debranching via sternotomy with Zone 0 TEVAR from the ascending aorta to just proximal to the celiac artery. A long periscope was placed from the true lumen in the distal abdominal aorta to the celiac artery to maintain perfusion. On follow-up, he required multiple coiling and ligation procedures to treat type II endoleaks in the thoracic aorta. With time, his aneurysm sac continued to enlarge due to distal false lumen perfusion and he presented for treatment.
PLAN: Our goal was to promote false lumen thrombosis and maintain patency of his visceral branches to treat his 7.6 cm thoracic aortic aneurysm. To do so, his aortic coverage was extended to just proximal to the superior mesenteric artery (SMA) utilizing the “knickerbocker” technique and false lumen embolization while protecting his celiac periscope. From bilateral femoral arterial access, the celiac periscope and true and false lumens were selected utilizing intravascular ultrasound and angiography. An angioplasty balloon was positioned into the celiac periscope to protect it during aortic manipulations. A tapered thoracic stent graft was deployed to extend true lumen endograft coverage to just proximal to the SMA and aggressively molded. A large plug was placed in the distal false lumen adjacent to the distal endograft. Completion angiogram demonstrated patency of the visceral branches and no further perfusion of the false lumen.
DISCUSSION: Persistent distal false lumen perfusion can lead to aneurysm sac enlargement with the potential for aortic rupture. Various techniques have been described to be safe and effective, but the presence of complex prior endovascular treatments can present unique anatomic challenges. In this case, we were able to successfully treat this patient with a large thoracic aneurysm while preserving his celiac periscope. 
Back to 2019 ePosters