Utility of dual longitudinal diameter-reducing ties in aortic arch thoracic endovascular aortic repair

Introduction

A 69-year-old man underwent open surgical ascending aortic replacement for type-A aortic dissection. Six months after this operation, he became symptomatic. There was persistent chest pain even though anti-hypertensive treatment was effective. Computed tomography angiography showed a widening false lumen (FL) in the aortic arch and in the thoracic aorta (Figure 1). The patient was not suitable for open aortic arch replacement due to high risk (logistic EuroSCORE 34.47%). Standard thoracic endovascular aortic repair (TEVAR) or branched endovascular repair (e.g. COOK) [1] was not considered due to insufficient landing zone distal to a right coronary artery venous bypass graft arising from the ascending aortic graft.

Case report

Stent-graft modification

The patient was selected for endovascular treatment with a physician-modified endograft (PMEG). Due to the presence of vein coronary bypass (VCB), an endograft with four fenestrations to the innominate artery (IA), left subclavian artery (LSA), left common carotid artery (LCCA) and VCB was planned. The PMEG was prepared on the basis of 3D printing [2, 3]. Fenestrations for the IA, LCCA, LSA and VCB were marked, burnt and their edges reinforced. The LSA was pre-cannulated. The VCB fenestration, located in the proximal endograft landing zone, was extra-large and “non-sealing” in nature (Figure 1).
Due to the sharply angled aortic arch it was not possible to insert the rigid delivery system using conventional femoral access and stiff guidewire in the ascending aorta. The delivery system was more rigid because it contained a PMEG with pre-cannulation guidewire (0.36 mm/0.014-inch Terumo Soft, Europe, Interleuvenlaan 40 3001 Leuven, Belgium) for the LSA, four fenestrations for arch vessels and VCB all marked and having reinforced edges and finally double guidewires (V-18 Control, Boston Scientific, USA) to constrain the endograft.
Therefore, externalized transapical guidewire technique (ETAG) was planned.
A Valiant Captivia thoracic endograft (Medtronic, Santa Rosa, CA, USA) of diameter 40 mm and length 200 mm was deployed in a sterile aortic arch model and after optimal positioning of the metal frame the VCB, IA, LCCA and LSA departure points were marked. Then the fenestrations were burned. Their edges were lined with the loop cut out from a snare (Indy OTW Vascular Retriever 8.0-35-55-40) for marking and strengthening the fenestration edge. The...


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