Zone 0 Thoracic Endovascular Aortic Repair With Chimney Grafts: A Case Report and Review of the Literature

Abstract

Open aortic repair has been the reference standard treatment of aortic arch pathologies. However, endovascular or hybrid therapies have become available for patients deemed at high risk of open surgical reconstruction. Surgical debranching still carries high morbidity and mortality in debilitated patients. Branch devices are currently limited in availability to phase I sites or for compassionate use, which can still cause significant delays in the delivery of the graft to the patient. Thoracic endovascular aortic repair (TEVAR) with parallel stent-grafting to maintain supra-aortic branch perfusion has been described as a feasible option for high-risk patients requiring urgent repair. We present the case of a symptomatic aortic arch aneurysm (Fig 1) requiring urgent repair in the setting of severe cardiac and pulmonary disease prohibiting open aortic arch reconstruction or debranching. The patient also had challenging vascular access with small, heavily calcified iliac arteries. We also reviewed the most current literature on endovascular therapy for aortic arch pathology. The patient underwent iliac artery endoconduit creation with a 10-mm Gore Viabahn (W.L. Gore & Associates, Flagstaff, Ariz). She underwent successful repair of her aortic arch aneurysm with zone 0 TEVAR, chimney grafts to the innominate (10-mm × 79-mm Gore Viabahn balloon-expandable endoprosthesis [VBX] and 10-mm × 59-mm VBX) and left carotid (7-mm × 79-mm VBX and 7-mm × 59-mm VBX) arteries, and left carotid artery to left subclavian artery bypass. She experienced resolution of her chest pain, and postoperative imaging demonstrated successful exclusion of the aortic arch aneurysm (Fig 2). Endovascular repair of aortic arch aneurysms can be safely performed in select patients who are not candidates for traditional aortic arch repair with zone 0 TEVAR and parallel stent-grafting to supra-aortic branch vessels.Fig 2Postoperative images showing successful exclusion of the aortic arch aneurysm with zone 0 thoracic endovascular aortic repair (TEVAR) and chimney grafts (A and B) to the innominate artery and left common carotid artery (white arrows). C, Three-dimensional reconstruction. D, Completion aortogram.View Large Image Figure ViewerDownload Hi-res image Download (PPT)