Salvage of a Failing EVAR Using the Off-The-Shelf T-Branch

Introduction - We report the case of a patient treated by an endovascular aortic repair (EVAR) for an infrarenal aneurysm that developed a type Ia endoleak. His aneurysms enlarged to 10 cm mandating a rapid repair. We successfully used an off-the-shelf thoracic branched graft with four branches to the visceral arteries by a bilateral femoral and left axillary artery approach. Methods - An 85-year-old male patient presented to our clinic for a 10 cm abdominal artic aneurysm (AAA). He was previously treated by EVAR for a 6 cm diameter aneurysms two years prior to his presentation using a Talent bifurcated device (Medtronic, Santa Rosa, Calif) with embolisation of the right hypogastric artery. He was lost to follow-up and presented one year later with an aortic rupture because of a distal migration of the main body of the device and a proximal type I endoleak. He was treated with a proximal cuff extension using an Endurant device (Medtronic, Santa Rosa, Calif). A year later, he presented again with a ruptured aneurysm due to a type III endoleak after disconnection of the main body and the proximal extension. He was managed urgently with a new Endurant bifurcated endograft extending from the most distal renal artery towards the previous bilateral iliac branches. During his Ct scan follow-up a proximal aortic dilation was noted reaching 35 mm in diameter at the level of the visceral aorta with a large posterior type Ia endoleak and a progression of his aneurysm to 10 cm (figure 1A). Since we could not wait for a custom made device, the off-the-shelf t-Branch (Cook, Bloomington, Ind) was used. It consists of a thoracic graft with four branches for each of the visceral arteries. It was introduced by the femoral artery and positioned in a way that the branches are 3 centimetres above their corresponding target vessels. Then through the left axillary approach each vessel was catheterised and stented one after the other (figure 1B). Results - The completion angiogram showed a successfully excluded aneurysm with absence of type I or III endoleak (figure 1C). All target vessels were patent. The patient had a smooth recovery; mainly he did not develop any signs of spinal cord ischemia and was discharged 10 days later. On the one-month follow-up Ct scan, the aneurysm was still excluded, no signs of endoleaks were noted and the visceral branches were still patent. Conclusion - The t-Branch is a ready to use endograft that is helpful in treated urgent cases of type Ia endoleaks following previous EVAR that could not wait for a custom made device. References1Sobocinski J, d’Utra G, O’Brien N, et al. Off-the-shelf fenestrated endografts: a realistic option for more than 70% of patients with juxtarenal aneurysms. J Endovasc Ther. 2012;19:165–172.2Bisdas T, Donas KP, Bosiers M, et al. Anatomical suitability of the t-branch stent-graft in patients with thoracoabdominal aortic aneurysms treated using custom-made multibranched endografts. J Endovasc Ther. 2013;20:672–677.3Adib Khanafer, Manar Khashram, Carmen-Maria Ruiz, Dana Mann, Andrew Laing. Use of the Off-the-Shelf t-Branch Device to Treat an Acute Type Ia Endoleak in a Symptomatic Juxtarenal Abdominal Aortic Aneurysm. J Endovasc Ther. 2016:23:212–215.