Society For Clinical Vascular Surgery

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Extension of Thoracic Aortic Stent Graft After False Lumen Entrapment of Frozen Elephant Trunk
Danielle Dombrowski, MD, Jeffrey Altshuler, MD, O. William Brown, MD.
Beaumont Health, Royal Oak, MI, USA.

Introduction: Deployment of thoracic stent grafts into the false lumen is a rare complication of the frozen elephant trunk procedure for complex proximal aortic disease, including dissection. The frozen elephant trunk procedure comprises ascending hemiarch replacement via median sternotomy and distal placement of thoracic endograft through the open lumen. As this procedure relies on direct visualization of the true lumen, the potential for deployment of the stent graft into the false lumen is ever present. Descriptions of this complication and its endovascular management are limited.
Methods: We describe a case of successful endovascular management of an entrapped frozen elephant trunk. The patient is a 61 year old male who underwent hemiarch repair and aortic valve replacement for acute type A dissection. 9 months ago, he subsequently needed a frozen elephant trunk procedure for enlarging descending aortic dissection and aneurysm. CT angiography was reviewed prior to the second stage of his repair and noted stent graft in the false lumen of his descending thoracic dissection (Figure 1, panel 1). Bilateral femoral artery access was obtained into the true lumen and intravascular ultrasound (IVUS) was used to find a fenestration approximately 2 cm superior to the take off of the celiac artery. The fenestration was successfully crossed with both a wire and catheter with angiographic confirmation (Figure 1, panel 2). A 40 x 40 x 15 mm Gore TAG device was deployed through the fenestration. Two additional graft pieces measuring 40 x 40 x 20 mm and 40 x 40 x 10 mm were placed to extend from the elephant trunk and ensure adequate graft overlap. Completion angiogram verified successful deployment(Figure 1, panel 3).
Results: Thoracic stent graft repair of entrapped frozen elephant trunk graft was achieved through use of IVUS and access to a supraceliac fenestration to the false lumen.
Conclusions: Entrapment of the frozen elephant trunk remains a rare but real potential complication in repair of complex aortic disease. We present a novel endovascular approach for repair through existing fenestrations to the false lumen.

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