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Branched Endovascular Repair Of Aortic Re-coarctation And Post-coarctation Descending Thoracic Aortic Aneurysm With The Off-the-shelf Thoracic Branch Endoprosthesis
Jesse Chait, D.O., Muhammed Varol, M.D., Allison K. Cabalka, M.D., Jason H. Anderson, M.D., Bernardo C. Mendes, M.D..
Mayo Clinic, Rochester, MN, USA.
Demographics A 74-year-old male with lifestyle-limiting claudication and medically refractory hypertension presented for evaluation.
History At age 7, primary end-to-end repair of a proximal descending thoracic aortic coarctation was performed. During evaluation for chest discomfort, computed tomography (CT) angiogram revealed recurrent coarctation of the aorta (reCoA) measuring 14 mm in diameter with a Doppler-derived gradient of 25-mmHg and post-coarctation descending thoracic aortic aneurysm (DTAA) measuring 50-mm in maximum diameter (Fig1A).
Plan An endovascular approach was recommended after multidisciplinary discussion. Centerline reconstruction demonstrated a distance between left subclavian artery (LSA) and reCoA of 14-mm, precluding use of a standard thoracic endograft. A landing zone proximal to LSA was evaluated and a zone 2 thoracic branch endoprosthesis (TBE) was considered feasible. Given the post-coarctation aneurysm, supraceliac aortic distal landing was planned. Under general anesthesia, bilateral femoral and left radial access were obtained and a 34x150x8-mm TBE was deployed in zone 2. A 24Frx65-cm sheath was utilized to stabilize the endograft just distal to the reCoA to prevent the curved nosecone delivery system from inadvertently dislodging the TBE distally during retrieval, given the small residual lumen. The LSA branch and distal endografts were deployed. An uninflated angioplasty balloon was placed in the LSA portal from radial access and a 22x20-mm ultra-non-compliant balloon was utilized to dilate the reCoA under rapid ventricular pacing, avoiding wind-socking of the graft with prolonged balloon inflation (Fig1B). Completion angiography and cone beam CT demonstrated successful resolution of the reCoA and aneurysm exclusion without evidence of complication and resolution of pressure gradient (Fig1C). The patient had an uneventful recovery with improved exercise tolerance.
Discussion Endovascular repair of reCoA and DTAA is considered first-line therapy, and repair with the TBE is attractive for a more robust proximal and distal seal compared to traditional covered stents. When present, aneurysms should be excluded before balloon aortoplasty. A short-shouldered balloon prevents encroachment on native aorta. Although side branch distortion is unlikely, an uninflated balloon placed in the portal allows for re-inflation following correction of the coarctation if necessary.
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