Complete endovascular debranching of the aortic arch: A report of two cases

Abstract

Patients suffering from aortic arch aneurysms continue to encounter few treatment options. Because of co-morbidities, most are deemed to not be open surgical candidates. The two cases presented here demonstrate a novel endovascular approach in the care of an arch aneurysm complicated by dissection. Even though final graft configurations differed slightly between the two cases, all three great vessels were successfully de-branched through the combination of standard endovascular aneurysm repair techniques and modifications to off-the-shelf devices. Aortic flow was compartmentalized in the ascending aorta at or near the level of the sinotubular junction. This was done with a physician-assembled endografts. One of these lumens was dedicated to the descending aorta, while the other was further divided into three channels used to stent the great vessels. Completion angiography demonstrated patency in the arch, great vessels, and descending aorta. No endoleaks have been reported. Although data is limited, this approach appears promising.

Keywords: Aortic arch aneurysm; endovascular aneurysm repair; endovascular de-branch; great vessels; off-the-shelf devices; thoracic manifold.

© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Figures

Figure 1.

Physician-assembled endografts used to treat patient 1: (a) thoracic double barrel and (b) thoracic manifold.

Figure 2.

Animation describing the sequential steps of implanting the graft system in patient 1: (a) the double barrel is placed through the right subclavian access; (b) the manifold is placed in the ipsilateral limb of the double barrel through the right subclavian access; (c) the transverse limb is brought up and over the arch and placed in the contralateral limb of the double barrel after wire access is secured in the left subclavian and left common carotid; and (d) the three great vessels are stented.

Figure 3.

Completion angiogram showing stents into each of the three great vessels.

Figure 4.

3D reconstruction of contrasted CT scans of Patient 1 from the 1 month follow-up.

Figure 5.

Physician-assembled endografts used to treat patient 2.

Figure 6.

3D reconstructions of contrasted CT scan of Patient 2 from the 1 month follow-up.