Multistage Total Endovascular Aortic Arch Repair for Chronic Complicated Type B Aortic Dissection with Bovine Arch Anatomy: A Case Report

Thoracic endovascular aortic repair is established for complicated type B aortic dissection, but extension of disease toward the aortic arch and involvement of supra-aortic branches may require technically demanding, individualized solutions. We report a multistage endovascular strategy in a 56-year-old man who presented with acute Stanford type B aortic dissection, hypertensive crisis, right renal malperfusion, and bovine arch anatomy. Right renal artery stenting was followed by thoracic endovascular aortic repair because of persistent pain and rapid enlargement of the distal arch. At 1 year, computed tomography angiography (CTA) demonstrated aneurysmal progression with type IA and IB endoleaks. A custom-made fenestrated arch endograft was deployed to preserve the common origin of the brachiocephalic and left common carotid arteries. Device malrotation caused acute bilateral carotid hypoperfusion, which was successfully treated by bailout parallel stenting; one bridging stent migrated to the abdominal aorta. Five months later, distal endograft extension excluded the type IB endoleak, and the migrated stent was retrieved with a snare. Follow-up imaging showed exclusion of both endoleaks, patent carotid vessels, and stable renal function. This case illustrates both the versatility and the procedural hazards of total endovascular arch repair. Meticulous CTA planning, immediate availability of bailout strategies, multidisciplinary expertise, and structured imaging surveillance are essential when treating complex post-dissection arch disease.