Physician Modified Endograft for Ruptured Dissecting Aortic Arch Aneurysm

Abstract

Background: Endovascular repair of thoracic aortic aneurysms (TAA) in elective settings has demonstrated successful clinical outcomes. However, life-threatening conditions such as rupture are more often managed with open surgical repair due to the high complexity of arch endovascular repair, lack of available off-the-shelf devices, and limited long-term data.

Case summary: A 49-year-old female with a recent history of prior ascending aortic repair for Type A₁₀ aortic dissection presented with chest pain and dyspnea. Chest computed tomography angiogram (CTA) revealed acute bilateral pulmonary emboli and a 6.2 cm post dissection aneurysm of the posterior aortic arch with the dissection extending to the right iliac artery. She was treated with thrombolysis and subsequently became hemodynamically unstable. Repeat CTA revealed a massive left hemithorax with concern for aortic arch rupture. Given significant cardiorespiratory compromise and recent open repair, she was considered unfit for redo open repair. Thoracic endovascular aortic repair (TEVAR) with a physician-modified endograft (PMEG) was planned. An Alpha Zenith endograft was modified adding an internal branch for the innominate artery and a fenestration for the left common carotid artery. The left subclavian artery was occluded with a microvascular plug and coil embolization up to the level of the vertebral artery. TEVAR PMEG extension to the celiac artery was performed followed by deployment of a Zenith dissection stent to the aortic bifurcation. Completion angiogram demonstrated successful aneurysm exclusion and patency of target vessels.

Conclusion: Endovascular treatment of ruptured TAA with PMEGs is feasible. This approach may be an alternative for unfit patients for open repair in emergent settings.

Keywords: aortic arch; aortic dissection; aortic rupture; physician-modified endograft; thoracic aortic aneurysm; thoracic endovascular aortic repair.

Figure 1.

Axial (A) and sagittal (B) preoperative computed tomography angiogram (CTA) with massive left hemothorax and dissected aneurysm extending from the descending thoracic aorta to the right common iliac artery. (C) Close-up sagittal cut with demonstration of the dissection flap (arrow) and innominate artery origin (asterisk).

Figure 2.

Cook Zenith Alpha proximal tapered graft used for procedure with fenestrations for the innominate and left carotid artery (A). Backtable modifications (B) were performed to create an internal branch at the innominate artery fenestration with a Viabahn stent.

Figure 3.

Operative angiogram sequence showing (A) Alpha Zenith endograft with modification for an internal branch for the innominate artery (IA) and fenestration for the left common carotid artery (LCCA). (B) IA fenestration cannulation (arrow). Left subclavian artery (LSCA) cannulation (C) and stenting (D). IA internal branch angiogram (E). Zenith dissection bare metal stent placement in the abdominal aorta (F).

Figure 4.

Completion arch (A) and abdominal aorta (B) angiogram with successful aneurysm exclusion and patency of target vessels.

Figure 5.

Intraoperative transesophageal echocardiogram with demonstration of atrial thrombus.

Figure 6.

Postoperative day 1 CTA (A) with presence of type Ic endoleak (arrow) and adequate resolution after secondary intervention on postoperative day 5 (arrow) (B).

Figure 7.

Sagittal (A) and axial (B) view of follow-up abdominal CTA with aneurysm sac shrinkage, PMEG vessel stent patency, and appropriate LSCA occlusion. Anterior (C) and anterolateral (D) 3D postoperative reconstruction of physician-modified endograft (PMEG) thoracic endovascular aortic repair (TEVAR).