Physician-modified fenestrated endograft for postdissection thoracoabdominal aortic aneurysm following provisional extension to induce complete attachment and renal artery stenting

Abstract

We have described a patient with a history of type A-11 dissection repair, who subsequently underwent thoracic endovascular aortic repair with distal bare metal dissection stents (provisional extension to induce complete attachment) and renal artery stenting for malperfusion. During the next 3 years, the thoracoabdominal aorta had continued to enlarge to 6.9 cm, despite false lumen embolization and thoracic endovascular aortic repair extension. Given the continued aortic enlargement, physician-modified fenestrated endovascular aortic repair was performed within the prior aortic and renal stents with successful aneurysm sealing. The results from the present case have illustrated that continued aneurysmal degeneration can occur after provisional extension to induce complete attachment and that subsequent physician-modified fenestrated endovascular aortic repair is feasible.

Keywords: Aneurysmal degeneration; Aortic dissection; Aortic remodeling; Fenestrated endovascular aortic repair; Malperfusion; PETTICOAT; Provisional extension to induce complete attachment.

Fig 1

A, Axial view of computed tomography angiogram (CTA) after open ascending and transverse aortic repair showing distal aortic arch dilation to 4.9 cm. B, CTA showing false lumen perfusion of the celiac artery (white arrow). C, CTA showing false lumen perfusion of the inferior right renal artery (white arrow). D, CTA showing false lumen perfusion of the superior right renal artery (white arrow) and dissection of the left renal artery (black arrow).

Fig 2

Digital subtraction angiogram of the thoracic endovascular aortic repair (TEVAR) with provisional extension to induce complete attachment (PETTICOAT) stenting using bare metal Zenith dissection stents (black arrow) and iCast stenting of the duplicated right renal arteries (white arrows).

Fig 3

A, Axial computed tomography angiogram (CTA) at 4 months of follow-up after thoracic endovascular aortic repair (TEVAR) showing false lumen expansion of the distal aortic arch to 6.4 cm. B, CTA at 2 years after TEVAR deployment when the patient had presented with chest and back pain in the setting of further expansion of the thoracoabdominal aorta to 6.9 cm secondary to continued false lumen perfusion from a septal fenestration around the TEVAR extension.

Fig 4

A, Physician-modified fenestrated endograft (PMEG) with five anatomically specific fenestrations for the visceral vessels created on a tapered Zenith alpha thoracic stent graft. Temporary diameter-constraining ties (black arrow) were added to a trigger wire (red arrow) for temporary diameter reduction during deployment. B, Modified fenestrated endograft showing partial constraint with temporary ties (black arrow). C, Catheterization of the main right renal artery for balloon protection against inadvertent crushing during deployment of the PMEG. D, Digital subtraction angiogram showing catheterization of the dissected left renal artery after deployment of the modified stent graft with alignment of each fenestration to its target vessel with sequential catheterization of each visceral–renal vessel.

Fig 5

Surveillance computed tomography angiograms (CTAs) showing endografts with complete aneurysm sealing without endoleak development and a decrease in aneurysm size to 6.3 cm. A, Three-dimensional reconstruction of the endovascular aortic repair. B, Decrease in aneurysm size to 6.3 cm in axial view. C, Abdominal aorta with a celiac artery stent (white arrow). D, Abdominal aorta with superior mesenteric artery stent (black arrow) and superior right renal stent (white arrow). E, Abdominal aorta with inferior right (white arrow) and left (black arrow) renal stents.