PMC7320213_01
(A) Sagittal computed tomography angiogram (CTA), revealing a 6 cm distal anastomotic pseudo-aneurysm, projecting anteriorly into the posterior aspect of the sternum. (B) Sagittal view CTA revealing chronic aortic dissection, extending distally from the left subclavian artery.
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Computed tomography angiography (CTA) revealed a voluminous pseudo-aneurysm of the distal anastomosis (largest diameter 60 mm) which projected anteriorly into the posterior aspect of the sternum (Fig. 1A). Significant compression of the true lumen was visible (maximum diameter of 8.4 mm in zone 7), although both lumens were patent throughout (Fig. 1B).
Post-operative occluder implantation computed tomography angiogram. Although significant sac thrombosis occurred, residual sac perfusion remains visible.
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Chicago, IL, USA) was performed initially. CTA confirmed proper positioning of the plug, with partial thrombosis of the pseudo-aneurysm, although residual sac perfusion was still visible (Fig. 2).
Schematic representation of the endovascular steps employed in this intervention. (A) Firstly, thoracic endovascular aneurysm repair (TEVAR; Conformable GORE TAG 21-21-100 [W.L. Gore and Associates, Flagstaff, AZ, USA) with deployment in the proximal descending thoracic aorta, distal to the left subclavian artery take off (zone 3). (B) A second TEVAR, as well as a self expanding covered stent, were then positioned for deployment in zone 0. (C) Parallel graft (PG) deployment. (D) Distal parallel graft extension with a balloon expandable covered stent (Viabahn VBX Balloon Expandable Endoprosthesis, 11-79; W.L. Gore and Associates).
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Associates, Flagstaff, AZ, USA) was initially navigated into the descending thoracic aorta and deployed in Ishimaru Zone 3 (Fig. 3A). A second thoracic endograft (Conformable Gore and Associates) was advanced into the ascending aorta, parallel to the thoracic stent graft. A self expanding covered stent (Viabahn Endoprosthesis 9-100; W.L. Gore and Associates) was then positioned inside the sheath, anchored in the brachiocephalic trunk ostia (Fig. 3B). Under rapid pacing, TEVAR was deployed in zone 0, immediately after which the self expanding covered stent was opened (Fig. 3C). Gore and Associates) was then positioned distal to the previous self expanding covered stent graft, and inflated to an intended diameter of 16 mm, in order to prolong the parallel graft up to the brachiocephalic trunk bifurcation (Fig. 3D).
(A) Completion angiography revealing total pseudo-aneurysm exclusion and normal perfusion of all supra-aortic trunks. (B) Completion angiography revealing left renal artery perfusion.
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(A-C) Six month post-operative computed tomography angiography confirming aneurysm exclusion.
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