Multi-Layered Parallel Grafting for Severely Angulated Thoracoabdominal Aortic Aneurysm

Abstract

Open repair of thoracoabdominal aortic aneurysm (TAAA) carries significant perioperative morbidity and mortality. Total endovascular repair of TAAA using branched, fenestrated stent-grafts have been performed with promising midterm results. However, severe angulation of the aorta as well as close proximity of the visceral and renal artery origins pose significant technical challenge in designing and implantation of branched, fenestrated stent-grafts. Parallel grafting offers an alternative technique, allowing an urgent total endovascular repair of symptomatic TAAA. We describe a novel technique of 4-vessel incorporation in a total endovascular repair of TAAA, using a multi-layered parallel grafting via unilateral brachial access. A 76-year-old male with severe chronic obstructive pulmonary disease and coronary artery disease presented with a symptomatic 9cm extent IV TAAA. The thoracic, and paravisceral segments of his aorta, as well as the iliac arteries were severely angulated, while the superior mesenteric and the celiac arteries had a common origin. An urgent total endovascular aortic repair was performed. The aorta and the iliac arteries were straightened by placing stiff wires from bilateral femoral arteries in a “buddy” fashion. Additionally, a brachio-femoral “body-floss” wire was established. Over this body-floss wire, thoracic stent grafts were deployed in multiple layers, alternating with parallel visceral and renal covered stents. Distally, a bifurcated modular stent-graft was deployed down to the iliacs, achieving complete aneurysm exclusion. Patient recovered well without complications and was discharged home in 5 days. Postoperative CT scan showed patent visceral and renal stents, and complete exclusion of the aneurysm without evidence of endoleak.