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Total Endovascular Aortic Arch Repair With Compassionate Use Nexus Duo Stent-Graft
Naveed A. Rahman, MD, Bradley S. Taylor, MD, Shahab Toursavadkohi, MD.
University of Maryland, Baltimore, MD, USA.
This 76-year-old male with history of severe coronary artery disease, previous endovascular aortic aneurysm repair, and overall high frailty presented with a 6 cm aortic arch aneurysm. He was deemed to not be an open surgical candidate due to history of myocardial infarction. He received FDA approval for compassionate use of the Nexus DUO, which is the first usage of this device within the United States. A left axillary to left common carotid artery bypass was performed using 8 mm ringed PTFE, with ligation of the proximal left common carotid artery. Total endovascular repair of his aortic arch aneurysm was performed from zone 0 to zone 4 via ultrasound-guided right common femoral artery access and open cutdown of the right axillary artery. The NEXUS Duo device had a 37 mm total body diameter and 150 cm total length, with a 20 mm innominate portal and 8 mm side branch for the left subclavian artery. There was a 40 x 55 mm NEXUS extension into zone 0 under transvenous pacing. The left subclavian artery was supported with an 11 mm x 5 cm Gore Viabahn stent. The innominate portal was reinforced with a 9 mm x 29 mm VBX stent. A NEXUS 37mm x 150mm stent covered the descending thoracic aorta to zone 4. Endovascular repair of the right external iliac artery was completed with 12mm x 10 cm Gore Iliac Extender.Post-operative imaging demonstrated successful exclusion of the aortic arch fusiform aneurysm. The patient had a left-sided stroke with initial right sided weakness that resolved without long-term sequelae. Dysphagia necessitated a short-term gastrostomy tube which was subsequently removed. The patient is still alive 18 months later without any evidence of endoleak or other post-surgical complications. Evolution of endovascular aortic repair has steadily expanded into increasingly complex anatomical areas. The aortic arch, once exclusively the domain of high-risk open surgery, is now a focus of innovative endovascular solutions. This case highlights that aortic arch pathology in high-risk surgical aortic patients can be successfully treated endovascularly, obviating the need for sternotomy or hypothermic arrest with open repair. We present the technical details and outcome of the first NEXUS Duo device utilized in the United States.
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