Treatment for thoracoabdominal aortic aneurysm by fenestrated endovascular aortic repair with physician-modified stent graft

Abstract

Despite being widely used for several years, the endovascular aortic repair (EVAR) of a thoracoabdominal aneurysm (TAAA) remains challenging, particularly the revascularization of the abdominal aortic visceral branches. A 66-year-old male was admitted to hospital with abdominal bloating and pain. Computed tomographic angiography (CTA) confirmed a Crawford type III TAAA from the distal descending aorta to the suprarenal abdominal aorta that involved the celiac axis, accompanied with an occlusion of the left subclavian artery. Fenestrated-EVAR was performed successfully and 1 week later CTA showed a type III endoleak, which had resolved 3 months later, without stent migration or visceral artery occlusion. In this present case, the surgeons preferred to perform the procedure in three surgical stages, postponing the deployment of a covered stent in the CA fenestration to provide additional time for the development of collateral circulation to the spinal cord as a possible means of preventing postoperative paraplegia.

Keywords: Thoracoabdominal aortic aneurysm; endovascular aortic repair; fenestrated; physician-modified stent graft.

Figure 1.

Preoperative computed tomographic angiography of a 66-year-old male who complained of abdominal bloating and pain for 2 days: (A) three-dimensional image of the aorta and iliac artery; (B) two-dimensional image of the same structures. A thoracoabdominal aortic aneurysm (Crawford type III) from the distal descending aorta to the suprarenal abdominal aorta that involved the celiac axis, accompanied with an occlusion of the left subclavian artery, was diagnosed. The colour version of this figure is available at: http://imr.sagepub.com.

Figure 2.

Preoperative aortic measurements were obtained with the superior margin of the celiac axis as baseline in a 66-year-old male with a thoracoabdominal aortic aneurysm (Crawford type III) from the distal descending aorta to the suprarenal abdominal aorta that involved the celiac axis, accompanied with an occlusion of the left subclavian artery: (A) measurement of the clock position, distance 2nd baseline, and inner aortic angle of the abdominal branches; (B) central line of abdominal branches. The colour version of this figure is available at: http://imr.sagepub.com.

Figure 3.

Surgical procedure in a 66-year-old male with a thoracoabdominal aortic aneurysm (Crawford type III): (A) left subclavian artery (LSA) before stent implantation; (B) LSA post stent implantation; (C) preoperative digital subtraction angiography (DSA) of the aneurysm above the kidney; (D) preoperative DSA of the infrarenal aneurysm; (E) the guidewire and sheath were advanced through the superior mesenteric artery and the bilateral renal arteries; (F) the stent was placed into the left renal artery; (G) the stent was placed into the right renal artery; (H) the aortic covered stent was released; (I) the stent was placed into the infrarenal aneurysm; (J) DSA of the aneurysm above the kidney after release with the arrow showing the overflowing contrast medium; (K) DSA of the infrarenal aneurysm after release; (L) DSA after the guidewire was placed into the celiac axis (CA); (M) CA stent was implanted; (N) DSA of the aneurysm above the kidney after CA stenting; (O) DSA of the infrarenal aneurysm after CA stenting. The colour version of this figure is available at: http://imr.sagepub.com.

Figure 4.

The surgeon created four fenestrations in a 26 × 26 × 134 mm Zenith Flex thoracic stent graft (Cook Medical, Bloomington, IN, USA): (A) the fenestration in vitro; (B) the modified stent graft was sent back into the delivery system. The arrow shows the preloading guidewire. The colour version of this figure is available at: http://imr.sagepub.com.

Figure 5.

Postoperative computed tomographic angiography images at 1 week after the final surgical stage in a 66-year-old male with a thoracoabdominal aortic aneurysm (Crawford type III): (A) three-dimensional image of the aorta and iliac artery; (B–D) endoleak around the graft in axial, sagittal, and coronal images, respectively. The arrows show the endoleak at the section of CA. The colour version of this figure is available at: http://imr.sagepub.com.

Figure 6.

Postoperative computed tomographic angiography images at 3 months after the final surgical stage in a 66-year-old male with a thoracoabdominal aortic aneurysm (Crawford type III): (A) three-dimensional image of the aorta and iliac artery; (B–D) no endoleaks were observed at the celiac trunk, superior mesenteric artery, and renal artery levels, respectively. The colour version of this figure is available at: http://imr.sagepub.com.