Antegrade in situ fenestrated endovascular repair of a ruptured thoracoabdominal aortic aneurysm

Figures

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  Fig 1. Computed tomography angiography with three-dimensional reconstruction demonstrating an 8-cm extent 1 thoracoabdominal aortic aneurysm (TAAA) after previous thoracic endovascular aortic repair (TEVAR). A, There is a robust type IB endoleak (solid arrow) (C) distal to the previous thoracic stent graft (long dashed arrow). B, The mediastinal hematoma created a mass effect on the heart and pulmonary artery (short dashed arrow). The visceral (D) and pararenal (E) aorta were aneurysmal.

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  Fig 2. Balloon-expandable stenting is performed for all visceral and renal arteries. The celiac (A), super mesenteric artery (SMA) (B), and bilateral renal arteries (C) and (D) are done in sequential order as depicted. Celiac, SMA, right renal, and left renal arteries took 7, 5, 6, and 10 minutes for cannulation and stent placement, respectively. Yellow rings and red lines were added to highlight the origin and contour of the target vessels, respectively.

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  Fig 3. Antegrade laser in situ fenestration is created after aortic seal. A, The thoracic stent graft is deployed to achieve seal of the ruptured aorta. The laser probe is brought to a down-the-barrel view (B), followed by a profile view (C) for precise positioning. Gentle forward pressure is used with brief energy delivery to visualize a pop-through of the probe (D). Successful luminal access is angiographically confirmed (E). Yellow rings and red lines were added to highlight the origin and contour of the target vessels, respectively.

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  Fig 4. Bridge stenting is performed with balloon-expandable covered stents. The superior mesenteric artery (SMA) is revascularized first (A), followed by the renal arteries (B and C), and then finally the celiac artery (D), limiting visceral ischemia time. E, Completion angiography. The previous type IB endoleak is no longer seen. There are no endoleaks and/or component separations. All visceral stent grafts are patent without type II endoleaks or stenosis. Yellow rings and red lines were added to highlight the origin and contour of the target vessels, respectively.

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  Fig 5. Postoperative computed tomography angiography (CTA) on day 5 (A-C) and at 3 months (D-G) show patent branch stents without stenosis, complete aneurysm exclusion without endoleak, and aneurysm sac regression.