TAA11. Pushing the Limits of Proximal Sealing Zone for Emergency Thoracic Endovascular Aortic Repair by Periprocedural Combined Embolization for Acute Thoracic Aortic Aneurysm Rupture: In the Middle of the Night

Abstract

Inadequacy of a proximal landing zone (zone 3 or 4) is often a limitation for thoracic endovascular aortic repair (TEVAR), particularly in acute situations. We present a completely new technique of tackling this issue during emergency TEVAR for a ruptured aneurysm of the descending thoracic aorta encroaching on the lesser curvature of the arch. A 66-year-old man was admitted with acute thoracic back pain. Contrast-enhanced computed tomography revealed contained rupture from aneurysm and type B dissection just caudal to the left subclavian artery. Proximal landing at zone 2 was inadequate. TEVAR with debranching and revascularization of neck arteries was an option but was ruled out because of the patient's comorbidities. Branched TEVAR was not an option because of latency in device delivery. Chimney technique was not used because of risk of type IA endoleak. After a left carotid-subclavian bypass (because of dominant left vertebral artery), we deployed a Zenith Alpha thoracic stent graft (ZTA-PT-40-36-217; Cook Medical, Bloomington, Ind) covering the left subclavian artery. However, because of inadequate proximal landing area inferiorly, the inferior margin of the stent graft opened in the aneurysm sac, giving rise to a type IA endoleak (Fig 1). We entered the aneurysm sac through the left subclavian artery and deployed a few Azur detachable macrocoils (Terumo Interventional Systems, Somerset, NJ) for clot formation and stabilization (Fig 2). We then embolized the rest of the aneurysm all the way up to the stent graft margin and also the proximal subclavian artery with Onyx (ev3, Covidien, Plymouth, Minn).Fig 2Aneurysm sac and proximal left subclavian artery are adequately embolized with detachable macrocoils and Onyx.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Computed tomography angiography 1 day after TEVAR showed complete exclusion of the aneurysm without any sign of endoleak as well as a stable and well-functioning stent graft. The patient is doing well 3 months after the procedure. To our knowledge, no similar case of concomitant embolization of aneurysm sac with TEVAR by combined coils and Onyx through the subclavian artery has been described in the literature. This technique was safe and can be used as an alternative, particularly in an emergency situation. However, long-term outcome of the technique is still awaited.