Contained rupture of arch aneurysm managed with total arch, frozen elephant trunk and endograft

Abstract

We here describe a complex case of a 75-year-old man presenting with contained rupture of an aortic arch aneurysm in the presence of a second thoracic aortic aneurysm. He was managed with emergent total arch replacement with frozen elephant trunk. Another stent-graft was used to achieve hemostasis at the distal anastomosis. He later underwent TEVAR extension to manage his second aneurysm in a staged fashion. This case demonstrates a number of important concepts in the evolving interaction between open and endovascular therapies of the aortic arch, particularly in the emergent setting.

Figure 1.. Pre-operative CT angiography of the thoracic aorta.

(A) Between the origins of the left common carotid and left subclavian arteries (LSCA), there was a 3.7 × 4.4 × 5.2 cm aneurysm directed towards the left, inferiorly and posteriorly. A second 4.3 cm saccular aneurysm arose from left lateral wall of the descending thoracic aorta. (B) The presence of peri-aneurysmal fluid, left hemothorax, and hemopericardium as well as his clinical presentation, confirmed relatively acute contained rupture (Figure 1B).

Figure 2.. Operative sequence.

(A) First a TEVAR was deployed retrograde from the femoral artery through to the thoracic aorta with its bare Dacron end protruding from the cut edge of the distal aorta. (B) A trifurcated arch graft was sown to the cut edge of the distal aortic arch and sequentially the LSCA, LCC and innominate arteries were anastomsed. (C) The final result showing total arch replacement.

Figure 3.. Post-operative CT angiography of the thoracic aorta.

(A) Interval CT angiogram re-demonstrated the second saccular aneurysm which had now grown to 2.9 × 3.8 cm, as well as two PAUs. The patient was offered endovascular repair which we performed 13 weeks after the index procedure. (B) He underwent TEVAR extension with 36 × 200 mm TerumoAortic Relay Plus endograft with use of a spinal drain. Completion angiogram revealed no endoleak and the final CT shows exclusion of the second aneurysm and PAUs.