Trans-axillary Repair Of A Symptomatic Thoracoabdominal Aortic Aneurysm With Concomitant Aortoiliac Occlusive Disease
Stephen Hayes, BS, Jonathan Parker, BS, Christopher Murter, MD, Samer Alharthi, MD, MPH, David Dexter, MD, Jean Panneton, MD, Animesh Rathore, MBBS.
Eastern Virginia Medical School, Norfolk, VA, USA.
DEMOGRAPHICS: 50-year-old white male with multiple comorbidities. HISTORY: He presented with right flank pain and was found to have symptomatic type V thoracoabdominal aneurysm (TAAA) with concomitant infrarenal aortic occlusion. Computed tomography angiography (CTA) demonstrated interval expansion >1cm over a 3 month period. PLAN: A multidisciplinary team reviewed case options, including surgical open repair versus endovascular repair. Given his multiple comorbidities precluding open repair (coronary artery disease, myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, recent stroke, and nonhealing sacral decubitus ulcer) we planned for endovascular repair using a physician-modified bifurcated endograft delivered antegrade via left axillary artery. Back-table physician-modification included endograft deployment on sterile back-table (Medtronic Endurant II, 28x13x166mm), removal of suprarenal fixation, and re-sheathing in reversed configuration. The modified endograft was advanced into thoracic aorta over guidewire via left axillary access. The ipsilateral limb was deployed into the SMA and followed by a Gore iliac limb (16x10x7mm) for extension. A type III endoleak was identified at the overlap and excluded with a Medtronic iliac limb (16x16x93mm). Celiac artery was selected from the contralateral gate and two VBX covered stent grafts (8x79mm, 11x79mm) were deployed and post-dilated to 16mm proximally. Endoanchors were placed proximally to prevent migration and endoleak. Left axillary artery to left external iliac bypass was performed to address his nonhealing sacral ulcer. The patient had an acceptable short-term outcome with pain resolution and successful endovascular repair evidenced by CTA on post-operative day (POD) 23 (figure 1). He was discharged with home health on POD 39. He presented at an outside hospital on POD 43 with a fall and liver laceration leading to hemorrhagic shock and was made comfort care. DISCUSSION: Open TAAA repair is associated with hemodynamically demanding events such as blood loss and aortic cross-clamping leading to perioperative organ ischemia, particularly of the kidneys and spinal cord. Endovascular repair is preferred to open surgical repair in high-risk surgical patients but standard transfemoral approach was precluded in our patient. We describe a novel technique of back-table modified endograft in reverse configuration deployed antegrade via left axillary access combined with axillo-iliac bypass.
Back to 2022 Abstracts