A 65-year-old male with hypertension and diabetes mellitus complained of sudden thoraco-abdominal pain. At history he referred to be in treatment with antiplatelet and anti-hypertensive drugs. Patient denied any previous family history of similar pathology. CT-scan showed an ATBAD, from left subclavian artery (LSA) to the superior mesenteric artery (SMA), and a 72 mm large infrarenal AAA. CT-angiography showed a significant true lumen compression from an expanding false lumen (Fig. 1, Fig. 2, Fig. 3). No malperfusions symptoms or signs were evident. Uncontrollable systemic hypertension and pain (thoracic and abdominal) were the indications to treatment. To reduce the invasiveness of the procedures and address simultaneously both ATBAD and AAA a totally endovascular approach was chosen.
Intervention was conducted without placement of spinal drain.
In our vascular operating room, under general anesthesia and systemic heparinization (ACT > 250 s), a bilateral surgical common femoral artery (CFA) and a bilateral percutaneous brachial artery (BA) accesses were gained. A through and through wire from the right CFA to the right BA (bodyfloss technique) was constructed in consideration of the arch anatomy and to create a stable platform for the thoracic stent-graft advancement and deployment by applying adequate tension to the bodyfloss wire.
An adequate proximal landing zone was identified in zone 2 Hishimaru aortic arch. To maintain LSA perfusion a chimney was planned. From the left BA access a 10 x 31 mm Silene covered stent (InSitu Technologies Inc, St. Paul, MN, USA) was advanced and parked at the origin of the LSA so that half of the length was positioned inside the aortic arch and the remaining into the LSA. A 40 x 223 mm Valiant Navion (Medtronic, Inc., Minneapolis, MN, USA) was placed and deployed in zone 2 aortic arch through the bodyfloss wire. At this stage, the Silene covered stent (InSitu Technologies Inc) was deployed. A kissing ballooning of both the Valiant Navion (Medtronic, Inc.) thoracic stent-graft and the LSA chimney was performed. Sizing of the thoracic and LSA devices were performed according to the current understandings. The control angiography confirmed the adequate proximal sealing, the absence of leakages and the maintained LAS patency.
The second step consisted of endovascular aneurysm repair (EVAR) carried with a 32 mm bifurcated ENDURANT II (Medtronic, Inc.) stent-graft from the infrarenal aorta to both common iliacs carried with the use of the speed cannulation gate technique. The control angiography confirmed the adequate proximal and distal sealing, the absence of leakages and the maintained internal iliacs patency.
The third step was performed with the placement of a 36 x 180 mm Zenith endovascular dissection stent (Cook Medical, Bloomington, IN, USA) between the thoracic and the abdominal stent-graft. This bare metal stent is intended to supports the collapsed true lumen without covering the reno-visceral branches as reported in the PETTICOAT (provisional extension to induce complete attachment) technique (Fig. 4). The final angiographic control confirmed the above mentioned partial findings and the maintained patency of reno-visceral arteries and a reduced refueling of the false lumen.
After procedure the patient was transferred in the intensive care unit (ICU) for monotoring of vital functions where the extubation was carried after 12 h with no complications or signs of spinal cord ischemia (SCI). On the second postoperative day the patient was transferred from ICU and discharged at home after seven days.
The one year CT angiogarphy showed good placement of thoracic and abdominal graft with good remodeling of false lumen in absence of symptoms and complete exclusion of AAA.