PMC10027482_01
CT Aortogram of the chest demonstrating the dissected thoracic aorta with a large aneurysmal cavity of the distal arch and proximal descending aorta. (
A
) Axial view. (
B
) Sagittal view.
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It also showed a large aneurysm starting at the base of the left subclavian artery and extending to mid descending thoracic aorta measuring 7.8 cm at maximal diameter ( Fig. 1 ).
Operative image showing the debranching graft with two limbs bypassing the innominate artery and left common carotid artery (black arrows) and the third limb reserved for future direct transaortic TAVR (
blue arrow
).
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The third limb of the trifurcated graft was tied and left in the mediastinum as an access for the future planned TAVR procedure ( Fig. 2 ). 
Postdeployment of three overlapping TEVAR grafts. (
A
) 3D reconstruction of the thoracic aorta post TEVAR. (
B
) Coronal reconstruction of the thoracic aorta showing complete thrombosis of the false lumen in the thoracic aorta proximal to the distal landing zone.
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TEVAR through a cut down on the right femoral artery. Three overlapping endovascular stent grafts size 32 x142 mm (Cook Zenith TX2 endovascular graft) were deployed starting just above the level of the debranching graft and covering the whole thoracic aorta down to 4 cm above the origin of the celiac artery ( Fig. 3A ). Postoperative CT scan showed complete thrombosis of the false lumen in the thoracic aorta proximal to the distal landing zone ( Fig. 3B ). 
Fluoroscopic image post V-I-V TAVR deployment showing the different angles of the thoracic aorta (
black arrows
).
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Size 26 Edward's Sapien 3 valve was deployed inside the previous valve over a Safari wire ( Fig. 4 ) without complications and there was no evidence of any paravalvular leak.