Abstract
INTRODUCTION: Thoracic endovascular aortic repair (TEVAR) has replaced open surgery for descending thoracic aortic pathology. Achieving a suitable proximal seal may necessitate hybrid repair involving cervical debranching, which carries risks. Alternatively, if a total endovascular solution is being attempted, parallel grafts or physician modified devices can be used. These have not, however, been designed specifically for this purpose. Branched thoracic endografts represent an evolution in stent graft design for the aortic arch. Single branched off the shelf designs are available, but multibranched designs are custom made, limiting their emergency use. Here, the successful use of a repurposed custom made triple branched endograft for a complicated acute type B aortic dissection (TBAD) with rapid false lumen expansion is reported. REPORT: An 84 year old man presented with a three day history of chest pain and worsening breathlessness. He had had a previous episode of acute TBAD a month earlier, managed with blood pressure control. Computed tomography angiography (CTA) revealed a left pleural effusion and an aortic dissection extending from the left subclavian artery to the aortic bifurcation. The proximal descending aortic diameter had rapidly expanded to 67 mm. To treat the patient, a custom made triple branched endograft, initially intended for a different patient, was used. Follow up CTA showed satisfactory positioning of the stent graft with no evidence of endoleak, complete false lumen thrombosis, and satisfactory aortic remodelling. DISCUSSION: Acute TBAD remains a significant therapeutic challenge, especially when complications arise. TEVAR is recommended, but standard endografts may require full head and neck vessel debranching to ensure a proximal seal, which can be achieved by either open surgery or through endovascular means. This case demonstrates the applicability of a multibranched arch endograft in the emergency setting, which fortunately was available in the unit. Although these cases are rare, it is believed that development of a three vessel off the shelf solution should be considered.