Two-staged endovascular treatment of thoracoabdominal aneurysm with use of T-branch device: timing of intervention

Endovascular treatment of (TAAA) with t-Branch multibranched stent graft is a complex procedure. Spinal cord injury is one of the most devastating complication of endovascular TAAA repair and several intraoperative maneuvers can be used to prevent it.

Patient of 69 years old, male, with symptomatic TAAA type IV (Crawford), arterial hypertension III grade, multivessel coronary artery disease, severe stenosis of left renal artery with laboratory signs of impaired renal function (CC – 50 ml/min) was admitted to endovascular treatment.. For the safety reasons in order to prevent spinal cord ischemia endovascular closure of contralateral hypogastric artery had been planned to be performed as the second stage of the procedure.

Under the endotracheal anesthesia access to both femoral and left subclavian was performed. As a first step left renal artery was stented with stent Monorail 6 mm. First Zenith t-BRANCH 34mm device was released in thoracic aorta via rCFA. Zenith Spiral-Z bifurcated device to ipsilateral leg level secondary. Contralateral device was delivered and released through lCFA access. Stent-graft «Fluency» 8mm and «Complete SE» 9mm stent was implanted in RRA, through RFA covered stent-graft «Advanta V12» 8 mm was delivered and implanted in LRA. Through LSA «Advanta V12» 10 mm was implanted in SMA. Following that coeliac trunk was stented with «Advanta V12» 10 mm. Control angiogram was performed. All endovascular devices were completely released and all visceral branches were patient with moderate right-side distal endoleak. So we decided not to occlude the right hypogastric artery simultaneously to prevent malperfusion of lower part of spinal cord. On 10 day postop patient complained for recurrent pain in lower abdomen. Occlusion of right internal iliac artery with stent-grafting of right common iliac was performed in an urgent way.

Conclusion: Technique of staged procedure in endovascular treatment of thoracoabdominal aneurysm is an effective method for prevention of spinal cord ischemia. The issue of distal 1 type endoleak should be taken into account while making the decision on the optimal procedure timing.