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TAMBE To Address Type 1a Endoleak In The Setting Of Multiple Parallel Stent Grafts
Austin T. Pierce, MD, Victor J. Davila, MD, William M. Stone, MD, Andrew J. Meltzer, MD.
Mayo Clinic Arizona, Phoenix, AZ, USA.
DEMOGRAPHICS:
The patient is a 77-year-old male with a past medical history significant for gout, hyperlipidemia, hypothyroidism, hypertension, stroke, pulmonary embolism, atrial fibrillation (not on anticoagulation), coronary artery disease status post stenting, type 2 diabetes, and an aortic aneurysm status post multiple interventions outlined below.
HISTORY:
Initial intervention consisted of an infrarenal EVAR (Cook Zenith) in 2019 at an outside institution. This repair was complicated by partial coverage of the right renal artery, necessitating covered stenting (iCast). A type 1A endoleak with sac expansion was present on surveillance imaging. The outside institution performed stenting of the bilateral renal and superior mesenteric arteries and cranial extension with a Treo endograft in a parallel stent configuration proximally to the level between the celiac and superior mesenteric arteries. The patient was referred to our hospital after a persistent type 1A endoleak was noted.
PLAN:We planned to extend endograft coverage cranially with a Gore thoracoabdominal multibranch endoprosthesis (TAMBE) device, bridging the device portals to the existing parallel stent grafts with Gore VBX stents. The orientation of the parallel stent grafts necessitated rotating the device 90 degrees and bridging the portals to the visceral targets in a non-standard configuration.
DISCUSSION:Proximal aortic neck dilation (AND) after infrarenal EVAR is a challenging problem that affects roughly 20-25% of patients within 10 years of their index repair. This substantially increases the risk of a type 1A endoleak, requiring reintervention. Contemporary methods to address type 1A endoleaks include open explantation and reconstruction, physician modified endografts (PMEG), fenestrated custom-made devices (CMD), and cuff extensions with parallel stent grafting. Many of these patients are frail and may be unfit for open reconstruction and not all institutions have access to custom endografts which also are limited in the number of fenestrations that can be included. PMEG is a challenging option that is not on IFU. Our team demonstrated the feasibility of type 1A endoleak repair with the GORE off-the-shelf TAMBE device in the setting of failed cuff extension with multiple parallel stent grafts. At 6 months, the patient has patent celiac, superior mesenteric, and bilateral renal arteries with no type 1A endoleak or sac expansion.
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