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Aortic Arch Degeneration After Thoracic Branch Endoprosthesis
Christopher Pedersen, MD, Jeffrey Jim, MD.
Allina Health Minneapolis Heart Institute, Minneapolis, MN, USA.
DEMOGRAPHICS51-year-old male with past medical history of hypertension and tobacco use. No family history of connective tissue disorders.
HISTORYThe patient presented with an acute type B
3-11 aortic dissection (TBAD) initially managed with impulse control. He developed right lower extremity malperfusion two days into his admission. He was treated with a thoracic branched endoprosthesis (TBE) and right common iliac stent placement. He was discharged on postoperative day 5. On follow-up imaging at one year, he has a proximal type 1A endoleak with persistent filling of the false lumen and aneurysmal degeneration of his aorta to >7 cm.
PLANThe patient underwent a left carotid to subclavian artery bypass followed by open arch reconstruction with frozen elephant trunk using a Thoraflex Hybrid prosthesis. Two months later, he underwent extension of the aortic repair with placement of an additional thoracic endograft proximal to the celiac artery. The aneurysm was addressed by utilizing a “candy-plug” technique and a modified thoracic stent graft was placed into the false lumen and the lumen occluded with an embolization plug.
DISCUSSIONThoracic endovascular aortic repair (TEVAR) is considered the first line treatment option for patients who present with complicated TBAD. The introduction of TBE expands anatomic indications for TEVAR. However, endoleaks related to TBE can be challenging to manage. In this case, a hybrid, multi-stage approach was undertaken to address the proximal endoleak as well as the rapidly enlarging aneurysm. An open arch reconstruction was undertaken as there was an inadequate proximal landing zone for a purely endovascular treatment. The “candy-plug” technique allowed endovascular management for the remaining aorta and avoidance of the complications associated with open thoracoabdominal aortic repair.
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