Hybrid Repair of a Giant Descending Thoracic Aortic Aneurysm with Hostile Iliac Access: A Case Report of the use of Merit Wrapsody as an Endoconduit for TEVAR

Background: Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for descending thoracic aortic aneurysms (DTAA) in high-risk patients, but adequate iliac access is a prerequisite. Hostile iliac anatomy encountered in up to 30% of candi dates constitutes one of the most challenging obstacles to successful endograft delivery. Case Report: An 83-year-old woman with multiple comorbidities presented with refractory chest pain caused by acute expansion of a giant DTAA measuring 104 mm. Computed tomography angiography (CTA) revealed complete occlusion of the right com mon iliac artery and severe fibrodysplastic changes of the left iliac axis with alternating aneurysmal dilatations and sub-occlusive segments. A hybrid strategy was employed: complex recanalization of the left iliac axis was accomplished via an antegrade brachial approach using the body-wire technique, followed by angioplasty and structural stabilization with a Wrapsody covered stent (Merit Medical), enabling safe deployment of two E-vita thoracic endografts (JOTEC). Right lower-limb perfusion was re established with a crossover femorofemoral bypass using an ePTFE graft. Conclusion: This case demonstrates that the integration of advanced endovascular manoeuvres, contemporary covered stenting technology, and conventional surgical bypass constitutes an effective and reproducible strategy for managing urgent aortic pathology in patients with severely compromised iliac anatomy.