Mendes, Bernardo C.

Purpose: To describe the technical aspects of a thoracoabdominal aortic aneurysm (TAAA) repair using a patient-specific fenestrated-branched stent-graft. Technique: The technique is demonstrated in a 69-year-old man with a 6.2-cm asymptomatic type III TAAA. A patient-specific fenestrated-branched stent-graft was designed with 2 down-going directional branches for the celiac and superior mesenteric arteries and 2 reinforced fenestrations for the renal arteries. The procedure was performed under general anesthesia and included sequential stenting of the celiac, superior mesenteric, and bilateral renal arteries. The patient was discharged from the hospital on postoperative day 5 with no complications. Follow-up computed tomography angiography demonstrated exclusion of the aneurysm and patent target vessels at 12-month follow-up. Conclusion: This article and illustrated video highlight the steps for procedure planning and implantation of fenestrated and branched endografts. As these techniques continue to evolve, outcomes are expected to be equivalent or improved as compared to those of long-established open repair.

Purpose: To present a rare case of disseminated intravascular coagulation (DIC) after thoracic endovascular aortic repair (TEVAR) and its novel treatment. Case Report: A 55-year-old man presented with DIC 10 months after TEVAR for chronic type B aortic dissection and descending thoracic aortic aneurysm. He had persistent retrograde flow in the false lumen with a stable aneurysm diameter. The false lumen was embolized with multiple Amplatzer plugs, which promoted false lumen thrombosis. Laboratory evaluation on postoperative day 7 demonstrated resolution of the coagulopathy. Follow-up at 18 months revealed no recurrent DIC; computed tomography angiography showed a stable aortic diameter and excluded thoracic aneurysm sac. Conclusion: This case demonstrates an unusual, potentially fatal postoperative complication of endovascular treatment of type B aortic dissections successfully treated with an innovative endovascular solution.

Purpose: To report the use of an investigational stent-graft to treat an ascending aortic aneurysm in a patient with a heart transplant. Case Report: A 48-year-old man presented with a 3.5×1.5-cm saccular aneurysm in the mid anterior ascending aorta, abutting the sternum. The patient’s history was notable for placement of a left ventricular assist device followed by orthotopic heart transplantation 2 years prior to treat end-stage familial dilated cardiomyopathy. Under compassionate use, a custom-designed ascending aortic stent-graft (Zenith Ascend) was successfully delivered via an 18-F system and deployed just distal to the origin of the left main coronary artery under pulmonary artery catheter–guided rapid ventricular pacing. The patient was discharged the next day, and 6-month follow-up was unremarkable. Imaging at 5 months showed an excluded aneurysm sac with no endoleak or migration. Conclusion: The ideal ascending aortic stent-graft should be low profile, conformable to the arch anatomy, with short tip delivery system and a stepwise deployment mechanism that allows precise placement relative to the ostia of the coronary arteries and the innominate artery. This case illustrates the advancement of endovascular techniques to the most challenging segment of the aorta to decrease morbidity and mortality in high-risk patients.