An Adjunct Strategy to Address Severe Aortic Tortuosity in Endovascular Management of Aortic Aneurysm
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0036
Submission Type:
Abstract Submission
Authors:
Adam Carroll (1), Ananya Shah (1), Robert King (1), Donald Jacobs (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions:
(1) University of Colorado Anschutz, Denver, CO
Submitting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Co-Author(s):
Ananya Shah
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University of Colorado Anschutz
University of Colorado Anschutz
Robert King
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University of Colorado Anschutz
University of Colorado Anschutz
Donald Jacobs
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University of Colorado Anschutz
University of Colorado Anschutz
*Muhammad Aftab
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University of Colorado Anschutz
University of Colorado Anschutz
*T. Brett Reece
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University of Colorado Anschutz
University of Colorado Anschutz
Presenting Author:
Ananya Shah
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University of Colorado Anschutz
University of Colorado Anschutz
Abstract:
Objective
Aortic tortuosity can pose significant difficulties in endovascular management of aortic disease. In addition to the operative difficulty of navigating a tortuous aorta, ensuring an ideal aortic position for successful stent-graft placement is paramount. We describe a case of a patient who required a complex, modified TEVAR technique for treatment of a descending thoracic aorta (DTA) aneurysm in a severely tortuous aorta.
Methods:
We discuss the case of a 73-year-old male with a severely tortuous aorta and a history of prior infrarenal EVAR who presented with an extensive large descending thoracic and abdominal aortic aneurysm for a planned TEVAR and 4v-PMEG.
Results:
After obtaining bilateral femoral access, bilateral Lunderquist wires were advanced to the thoracic aorta, and a 18Fr Dryseal was placed on the left and a 22Fr Dryseal on the right. His aorta had 3 significant angulations, the most substantial of which was 62 degrees above the diaphragm. For the initial TEVAR, in order to advance the 40-36 x 250 mm relay Pro thoracic stent-graft, a 22Fr 65cm dryseal sheath was exchanged to straighten out the aorta. This was then cut at the proximal end to allow for retraction and full release of the endograft which was placed just distal to the left subclavian.
After defining the visceral aorta anatomy through aortogram, the Treo PMEG was oriented. The second thoracic stent graft, a 36-32 x 150 mm relay Pro thoracic stent graft, was then advanced and deployed just superior to the celiac fenestration. Due to the tortuosity of the thoracic aorta, this graft lost seal with the PMEG graft when deployed. A trilobe balloon was used to cover the overlap between the two thoracic stent grafts, which caused the more distal graft to move even further away from the proximal one. A 34 x 100 mm Gore C TAG thoracic stent graft was then required to bridge the distal thoracic graft with the PMEG graft. A trilobed balloon was again used for the overlaps, this time resulting in a good seal without coverage of the celiac fenestration. The celiac artery, superior mesenteric artery (SMA), and right renal artery (RRA) were then cannulated, and the Treo graft was fully deployed. Following the placement of visceral fenestration and iliac stents, final angiography was done showing patency of all stented vessels, and no type I, 2, or 3 endoleak from the thoracic aorta through to the iliac arteries.
Conclusion:
Management of severely tortuous aortas can be challenging and complex, potentially requiring immediate modification of existing techniques in the operating room. Multidisciplinary collaboration at high volume aortic centers is necessary when severe tortuosity is present.
Aortic tortuosity can pose significant difficulties in endovascular management of aortic disease. In addition to the operative difficulty of navigating a tortuous aorta, ensuring an ideal aortic position for successful stent-graft placement is paramount. We describe a case of a patient who required a complex, modified TEVAR technique for treatment of a descending thoracic aorta (DTA) aneurysm in a severely tortuous aorta.
Methods:
We discuss the case of a 73-year-old male with a severely tortuous aorta and a history of prior infrarenal EVAR who presented with an extensive large descending thoracic and abdominal aortic aneurysm for a planned TEVAR and 4v-PMEG.
Results:
After obtaining bilateral femoral access, bilateral Lunderquist wires were advanced to the thoracic aorta, and a 18Fr Dryseal was placed on the left and a 22Fr Dryseal on the right. His aorta had 3 significant angulations, the most substantial of which was 62 degrees above the diaphragm. For the initial TEVAR, in order to advance the 40-36 x 250 mm relay Pro thoracic stent-graft, a 22Fr 65cm dryseal sheath was exchanged to straighten out the aorta. This was then cut at the proximal end to allow for retraction and full release of the endograft which was placed just distal to the left subclavian.
After defining the visceral aorta anatomy through aortogram, the Treo PMEG was oriented. The second thoracic stent graft, a 36-32 x 150 mm relay Pro thoracic stent graft, was then advanced and deployed just superior to the celiac fenestration. Due to the tortuosity of the thoracic aorta, this graft lost seal with the PMEG graft when deployed. A trilobe balloon was used to cover the overlap between the two thoracic stent grafts, which caused the more distal graft to move even further away from the proximal one. A 34 x 100 mm Gore C TAG thoracic stent graft was then required to bridge the distal thoracic graft with the PMEG graft. A trilobed balloon was again used for the overlaps, this time resulting in a good seal without coverage of the celiac fenestration. The celiac artery, superior mesenteric artery (SMA), and right renal artery (RRA) were then cannulated, and the Treo graft was fully deployed. Following the placement of visceral fenestration and iliac stents, final angiography was done showing patency of all stented vessels, and no type I, 2, or 3 endoleak from the thoracic aorta through to the iliac arteries.
Conclusion:
Management of severely tortuous aortas can be challenging and complex, potentially requiring immediate modification of existing techniques in the operating room. Multidisciplinary collaboration at high volume aortic centers is necessary when severe tortuosity is present.
Aortic Symposium:
Descending/Thoracoabdominal Aorta
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