Endovascular rescue of failed physician-modified multibranched endografts with fabric tear, using Gore thoracoabdominal multibranched endoprosthesis

Abstract

The thoracoabdominal multibranch endoprosthesis is a commercially available off-the-shelf four-vessel inner branched endograft for complex abdominal and thoracoabdominal aortic aneurysms. Type IIIb endoleak owing to fabric tear of fenestrated branched endovascular repair (FBEVAR) can be challenging, often requiring relining FBEVAR. Here, we present a case where thoracoabdominal multibranch endoprosthesis was used to reline the previous physician modified FBEVAR in a patient with a 10-cm extent IV thoracoabdominal aortic aneurysm distal to the previous open extent I thoracoabdominal aortic aneurysm repair.

Keywords: Fenestrated branched endovascular repair; Thoracoabdominal aortic aneurysm; Thoracoabdominal multibranch endoprosthesis.

Fig 1

(A) Three-dimensional reconstruction computed tomographic (CT) image showing extent IV thoracoabdominal aneurysm and left common iliac artery aneurysm. (B) Schematic of the patient's preoperative anatomy and previous open aortic graft replacements with patent intercostal artery present. (C) Left ureteral rupture seen with associated urine extravasation (circled).

Fig 2

(A) Physician-modified endograft (PMEG) with four visceral directional branch cuffs. The Intercostal fenestration is located on the posterior portion of the graft. (B) Alignment of intercostal fenestration with three-dimensional overlay imaging (circled) for optimal positioning of PMEG main body graft. (C) Completion angiogram of left iliac branch endoprosthesis device with Viabahn extension of internal iliac artery showing adequate flow with no endoleaks. (D) Schematic showing completion anatomy after four vessel fenestrated branched endovascular repair (FBEVAR). (E) Postoperative scan at 4 months showing sac regression to 9.9 cm from 10.7 cm.

Fig 3

(A) Type IIIb endoleak seen coming off the main body graft near the left renal artery stent (circled). (B) Intercostal artery was snorkel stented before deployment of thoracoabdominal multibranch endoprosthesis (TAMBE) main body graft (circled). (C) Labeled catheterization of all visceral and renal vessels before stent deployment. (D) Completion three-dimensional reconstruction of TAMBE within fenestrated branched endovascular repair (FBEVAR) with no endoleaks seen. (E) Schematic showing TAMBE inside previous FBEVAR. (F) Postoperative scan showing resolution of the type IIIb endoleak. CA, Celiac artery; LRA, left renal artery; RRA, right renal artery; SMA, superior mesenteric artery.