Floating Stent-Graft as a Support to Bridge an Unfavorable Renal Artery During Postdissection TAAA Repair Using a Multibranched Thoracoabdominal Endograft

Abstract

Purpose: To report an unusual endovascular technique to manage unfavorable renal artery anatomy encountered in an urgent case of symptomatic postdissection thoracoabdominal aortic aneurysm (TAAA) treated with an off-the-shelf multibranched device. Technique: The technique is demonstrated in a 77-year-old woman who had a history of previous open abdominal aortic aneurysm repair and an emergent procedure to implant a thoracic endograft and an aortic bare Z-stent (PETTICOAT) for acute Stanford type B dissection 7 years prior. The patient presented with a symptomatic, rapidly growing, postdissection TAAA. Endovascular treatment with a Zenith t-Branch was planned. After standard catheterization techniques failed in the left renal artery, a bailout maneuver was utilized to place a “floating” Viabahn stent-graft in the aneurysm sac to create sufficient support to deliver the bridging stent-grafts through the bare stent to the target left renal artery. The procedure was successful in excluding the TAAA and preserving perfusion to all target vessels. No neurological complications occurred. Six-month imaging follow-up confirmed the patency of the bridging stents. Conclusion: Remodeling changes after complex endovascular TAAA procedures often require the use of innovative techniques and materials during secondary procedures. In this case, the presence of a post-PETTICOAT bare aortic stent and hostile target artery anatomy increased the technical difficulty of t-Branch implantation. A “floating” stent-graft could be useful to reach challenging target vessels by providing additional support to bridging stent advancement and deployment.

Commentary: Urgent Repair of Postdissection Thoracoabdominal Aortic Aneurysms Using Branched Endografts

“…In the December 2020 issue of the JEVT , Rossi et al 6 describe a novel bailout technique they found useful in a postdissection TAAA case when a t-Branch implantation was hampered by bare stents from a PETTICOAT technique used during a prior thoracic endovascular aortic repair (TEVAR). Despite several attempts the tortuous left renal artery could not be cannulated so the authors suspended a Viabahn stent-graft in the cul-de-sac not connected to either the branch or the renal artery but held distally by the struts of the bare stent as well as by the relatively small aneurysm sac.…”