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Transcaval Access For Endovascular Repair Of A Descending Thoracic Aortic Aneurysm
Mark Barlek, D.O, Alessandro Vivacqua, MD, Jeffrey Altshuler, MD, Ahmad Jabri, MD, Brian Renard, MD, Otto W. Brown, MD.
Corewell Health Beaumont University Hospital, Royal Oak, MI, USA.
DEMOGRAPHICS: This is an 85-year-old female with a past medical history of a descending thoracic aortic aneurysm, atrial fibrillation, chronic kidney disease, hypertension and gastroesophageal reflux disease.
HISTORY: The patient's aneurysm was discovered in 2021 on an outpatient CT scan and measured 5.1cm. She was monitored as an outpatient with interval imaging. In 2025, the aneurysm had increased to a size of 6.2cm. The patient’s age and medical comorbidities precluded an open repair. The patient had significant aorto-iliac calcification that would not allow safe delivery of an endograft from femoral access or creating an iliac conduit.
PLAN: The patient’s case was discussed at our multidisciplinary aortic conference. Due to the significant aorto-iliac calcification, the decision was made to proceed with a transcaval delivery of the endograft to perform a thoracic endovascular aortic aneurysm repair (TEVAR). Right common femoral venous access was obtained to deliver the endograft, left common femoral artery access was used to perform an aortogram and the right axillary artery was accessed to deliver an aortic cuff if the closure device did not seal the cross over from the inferior vena cava (IVC) to the aorta. The left subclavian artery was occluded and was not accessed. An aortogram and venogram were obtained to find an appropriate crossing point of the IVC into the infrarenal aorta. Using an angled catheter and a hydrophilic guidewire, the wire and catheter were passed from the IVC into the aorta. The wire was snared and placed into the thoracic aorta and exchanged for a stiff wire. A Gore 22Fr sheath was advanced from the IVC into the aorta. A 34mm x 34mm x 150mm Gore TAG Conformable Thoracic Stent Graft was used to exclude the thoracic aortic aneurysm. Thoracic aortogram showed no evidence of an endoleak and appropriate position of the endograft. An Amplatzer PDA 10/8mm duct occluder was used to close the crossover from the IVC to the aorta. A venogram and aortogram were performed showing no evidence of contrast extravasation.
DISCUSSION: Significant aorto-iliac calcification can preclude the delivery of an endograft. If a patient is not a candidate for an open repair, there are limited options for treatment. Transcaval delivery of an endograft provides another method to perform a TEVAR in patients with severe aorto-iliac calcification.
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