case report : large thoracoabdominal aneurysm with narrow ... · 2 sessions to reduce paraplegia...

2018

Case Report : Large thoracoabdominal

aneurysm with narrow access vessels

MichelBosiers,MD

DepartmentofVascularSurgery,Münster

2018

Pa<ent details

•  80y,female

• Arterialhypertension

•  coronaryheartdisease,previousCABG

• COPDGoldIII

•  Thoracoabdominalaneurysm67mm

•  Externaliliac:6-7mmdiameter

2018

Planning

2018

What would be your treatment strategy?

• Openrepair• ConservaLvetreatment• Chimney/SandwichEVAR• Off-the-shelfbranchedendograQ• Custom-made-branchedendograQ• Custom-made-fenestratedendograQ• OtheropLon...

2018

Our concept

2sessionstoreduceparaplegiarisk

•  1.TEVARstarLngattheleveloftheleQsubclavianarterytoapproximately2cmproximaloftheceliactrunc

•  2.custommadebranchedendograQ,low-profiledevice(18F)dueto

narrowiliacs

2018

Planning

SMA

Celiactruncstenosed

LRA

RRA

2018

•  Stagedprocedureinordertoreduceparaplegiarisk:

1.Session:TEVAR(Zenithalpha,Cook)

ZTA-PT-36-32-209

2.Session:custommadelowprofile(18F)device(Cook)4branches

andbifurcatedendograQ;8weekslater

Treatment

2018

Treatment

FirstSession:TEVAR

2018

Treatment

Step1:deployingCMDbranchedendograQ(Cook)Step2:distalcompleLonwithbifurcatedendograQStep3:groinclosure(ProStarXLAbboa)Step4:12Fflexorsheath(Cook)fromtransaxillaryapproachFollowedby8Fsheath(Cook)

2018

Treatment: aAaching SMA

8x59mmAdvanta(Maquet)+10x50mmViabahn(Gore)

2018

Treatment: aAaching right renal artery

6x38mmAdvanta(Maquet)+6x50mmViabahn(Gore)

UpwardfacingRRA

2018

Treatment: aAaching leE renal artery

6x38mmAdvanta(Maquet)+6x100mmViabahn(Gore)

2018

Subtotalstenosed+excellentcollateralisationviaSMA

Treatment: aAaching celiac trunc

•  8x38mmAdvanta

(Maquet)

•  10mmAmplatzerPlug

(St.JudeMedical)

forbranchocclusion

2018

Result

2018

•  2daysatIntensivecareunit(standardatourinsLtuLon)

• Noparaplegia/paraparesis

• Dischargepostopday7

• CT-Scanpostop+followup(12months):

Noendoleak;Patentbranches

Results

2018

Ques<ons to Vascupedians

• WhatisyourpreferredbridgingstentgraQinupwardfacingrenal

arteries?

• DoyougenerallytreatoctogenarianswithTAAA?

•  Whatisyourtreatmentstrategytoreduceparaplegiarisk

•  ShouldbranchedendograQsonlybeperformedinspecialized

centers?