Complex Endovascular Aortic Repair With a Branched Endograft to Revascularize 5 Renovisceral Vessels and an Intercostal Artery in a Marfan Patient

Abstract

Purpose: To report a case of thoracoabdominal aortic aneurysm (TAAA) repair treated with a multibranched stent-graft including a prophylactic branch for a large intercostal artery in a Marfan patient at risk for spinal cord ischemia (SCI). Case Report: A 43-year-old man with Marfan syndrome presented with a type IV thoracoabdominal aortic aneurysm (TAAA) and history of multiple previous cardiac and aortic operations over the past 28 years. The maximum diameter of the aneurysm was 60 mm. The patient had 2 right renal arteries and 2 reimplanted segmental arteries (1 occluded). With the goal of preserving both right renal arteries and the large intercostal artery, a 6-branch, custom-made stent-graft was planned and manufactured. Bilateral femoral and right brachial artery access was used. The intercostal artery was catheterized and connected to the retrograde branch from a femoral access. Final angiography and predischarge computed tomography angiography (CTA) showed unimpeded flow to all 6 target vessels. The patient was discharged on postoperative day 10 without clinical signs of SCI. Six-month follow-up CTA demonstrated exclusion of the TAAA and patency of all 6 branches. Conclusion: Multibranched endovascular aortic repair with a branch to a large intercostal artery was technically feasible and clinically successful.

Endovascular Repair Using a 7-Branch Stent-Graft for a Thoracoabdominal Aortic Aneurysm With Variant Renovisceral Artery Anatomy

“…Moreover, the favorable angulation and diameters of the 7 TVs allowed them to be included in the branched device to decrease the risk of renal impairment and/or visceral malperfusion. Since the use of such a large number of branches was supported by recent experiences suggesting the feasibility of F/B-EVAR for 5 and 6 target vessels, 12,13 a 7-branch stent-graft was included in the options discussed with the patient, who agreed to this more complex treatment.…”

Parallel intercostal artery stenting and exclusion of symptomatic bucket-handle intercostal patch aneurysm

“… 13 , 14 , 15 Intercostal preservation has also been demonstrated during index fenestrated-branched endovascular aortic repair with dedicated side stents or scallops. 16 , 17 Intercostal artery stenting is rarely utilized in intercostal artery preservation during treatment of intercostal patch aneurysms but is feasible, particularly when parallel grafting can be utilized as demonstrated in a similar case by Tjaden et al. 18 That case also demonstrates the importance of test balloon occlusion of the intercostals with continuous neurologic monitoring prior to finalizing the operative plan, as was done with our patient as well, to mitigate spinal cord ischemia risk.…”

Fenestrated and Branched Endovascular Aortic Repair of Thoracoabdominal Aortic Aneurysm With More Than 4 Target Visceral Vessels due to Renovisceral Arterial Anatomical Variations: Feasibility and Early Results

“…The intercostal artery was revascularized to decrease the risk of spinal cord ischemia. 8 Several investigators have reported the feasibility and safety of F/B-EVAR. [1][2][3][21][22][23] The 30-day mortality was 1/12 patient, which is accepted as regard to the rate reported in previous reports.…”

“…Recently, 2 case reports addressed the feasibility of F/B-EVAR for 5 and 6 target visceral vessels (TVs) in the treatment of TAAA with renovisceral arterial anatomical variations demonstrating technical feasibility of F/B-EVAR even when the number of TVs exceeds 4. 7,8 However, whether time and effort to connect additional TVs is justified or may complicate outcomes of an already complex endovascular procedure is unclear, as well as patency rates of small renovisceral vessels.…”