Complex Endovascular Aortic Repair with a Branch for an Intercostal Artery in Marfan Patient

Abstract

Introduction: Spinal cord ischemia (SCI) caused by intercostal artery occlusion in combination with procedural factors such as hypotension is the Achilles heel of open and endovascular TAAA-repair report a case of branched endovascular aortic repair including a branch for a large intercostal artery as a protective method in a patient at risk for spinal cord ischemia (SCI). We report a case of branched EVAR (bEVAR) in a Marfan patient with a 6cm Type IV TAAA including a branch for a large previously re-implanted intercostal artery. Methods: A 43-year-old patient with known Marfan syndrome presented with a type IV thoraco-abdominal aortic aneurysm (TAAA) and history of multiple previous cardiac and aortic operations over the past 28 years. The maximum diameter of the aneurysm was 60mm. The patient had two right renal arteries and two re-implanted segmental arteries. With the goal to preserve both right renal arteries and one large intercostal artery a 6-branched custom-made stent-graft was planned and manufactured. A custom-made stent-graft (Cook Medical, Bjaeverskov, Denmark) was planned. The branched component was planned to land in the mid/distal descending thoracic aorta with antegrade branches for the CA, SMA and renal arteries and a retrograde branch on the opposite left side for the intercostal artery. The retrograde branch for the intercostal artery was positioned at 5:00 o'clock in order to allow a spiral course of the bridging covered stent to the origin of the vessel at 9:30 o'clock with a lower risk of kinking. Bilateral femoral and right brachial artery access was used. The intercostal artery was catheterized and connected to the retrograde branch from femoral access successfully. Results: Selective angiography of the target vessels and final angiography demonstrated good sealing and unimpeded branch-perfusion, without endoleak. The patient was discharged from hospital to home on postoperative day 10 without complications. Six-month-follow up CTA demonstrated unchanged well-fitting endo-graft-position with good sealing and patency of all six branches including the two branches on the right renal artery and the branch to the intercostal artery (Figure. 5). The TAAA-diameter had significantly decreased from 60mm to 42mm and no signs of endoleak were present. Conclusion: Branched endovascular aortic repair with a branch to a large intercostal artery was technically feasible and clinically successful. Disclosure: Tilo Kölbel has intellectual property with Cook Medical, receives royalties, research, travel and educational grants, speaking fees and is consultant and proctor with Cook Medical. Nikolaos Tsilimparis receives travel and educational grants, speaking fees and is proctor with Cook Medical.