Endovascular Aortic Arch Repair

Open repair is the standard for aneurysmal degeneration of the arch. A recent study showed that as many as 30% of patients surviving an initial type 1 aortic dissection repair required a subsequent intervention. Here, the authors describe a patient who survived a type 1 dissection repair five years prior to the index procedure. The patient was treated with a short ascending graft and mechanical valve. She had an extensive list of comorbidities including severe osteopenia, smoldering multiple myeloma, delayed sternal healing, open PDA ligation, endocarditis, and prior open dissection repair. She presented with chest pain and a 6.5 cm dissecting aneurysm of the arch. This video describes the endovascular strategy that was proposed and executed, given the patient and team’s reluctance to undergo an open repair.

The procedure is divided into two parts, beginning with the carotid bypass and left carotid subclavian transposition. This establishes flow to the head through the left subclavian artery. The second phase includes: deployment of stent segment 1 (fenestrated graft branching to the left subclavian), stent segment 2 (proximal ascending graft with short nose cone delivery system to deploy within the prior ascending graft), and stent segment 3 (distal extension limb). The result was excellent with complete apposition and seal, no endo leak, and no postoperative neurologic complications.