Modified Candy-plug Technique For Rapidly Enlarging Symptomatic Post Dissection Aneurysm: A Case Report
Erion Qaja, DO1, Edward Gifford, MD2, Robert Hagberg, MD2, Akhilesh Jain, MD2.
1Vascular Surgery, U Conn/Hartford Hospital, Hartford, CT, USA, 2U Conn/Hartford Hospital, Hartford, CT, USA.
DEMOGRAPHICS: This case report demonstrates novel use of a PTFE thoracic stent graft for “candy-plug” technique to exclude the aneurysmal false lumen in aneurysmal type B dissection with impending rupture.
HISTORY: Patient is a 45-year-old female with past history of Type-A aortic dissection who presented with rapidly enlarging thoracic aortic aneurysm. 10 weeks prior, she underwent aortic arch de-branching with elephant trunk in preparation for multistage repair. She had advanced COPD at baseline and was now debilitated on home oxygen after the redo sternotomy. CTA revealed chronic thoraco-abdominal dissection. Her thoracic aorta measured 6 cm in diameter and had grown by 5 mm in last 6 weeks. Abdominal aorta was normal in caliber. She was prohibitive surgical risk by cardiac as well as vascular surgery.
After bilateral femoral access, simultaneous stiff wire access to both the true and false lumen was obtained by crossing a septal fenestration in visceral aortal. An 8mm x 50mm Gore Viabhan stent was deployed on back-table and then subsequently slid on top of an undeployed 34 x 150 Gore thoracic stent graft and then anchored to mid-section of this graft with interrupted prolene.
A Cook Alpha thoracic stent graft was deployed into the true lumen ending just above the celiac artery. Simultaneously the modified Gore c-TAG was deployed in the false lumen matching the distal landing zone of Alpha stent graft. The narrowed portion of the Gore c-TAG Candy plug was now embolized using Amplatzer plug. Completion angiogram and on table cone beam CT demonstrated symmetrical deployment of both the stent grafts with exclusion of thoracic aortic aneurysm.
PLAN: Post operatively the patient did well. She required pigtail drainage of a retained left hemothorax. On multiple serial follow up CTA demonstrated continued exclusion of thoracic aneurysm and stable abdominal aorta without malperfusion. She is now one-year post op and remains asymptomatic with favorable sac remodeling and continued exclusion of thoracic aortic aneurysm.
DISCUSSION: Physician modified “Candy plug” technique can be a valuable adjunct in management of emergent post dissection thoracic aortic aneurysm in emergent settings in patients at high risk for open surgery.
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