Debranching and Endovascular Repair of Distal Anastomotic Leak after Ascending Aorta Replacement with Preoperatively Devised, Fenestrated and Branched Stent Grafts (Surgeon-Modified Fenestrated and Retrograde Branched Technique)

Abstract

A 79-year-old male who underwent emergency ascending replacement for type A acute aortic dissection 2 months earlier. Postoperative CT showed a Distal anastomotic leak and blood flow from multiple entries below the descending aorta into the false lumen, resulting in poor thrombosis and rapid aortic diameter enlargement, requiring additional therapeutic intervention at an early stage. It was difficult to perform total aortic arch replacement or hybrid arch repair with a commercially available device. After ethical approval had been obtained from the institutional review board, a commercially available stent graft (Relay Plus^®) was fenestrated with a 12-mm hole. Under general anesthesia, bypass grafting was performed between the bilateral axillary arteries and the left common carotid artery with a T-shaped ring supported e-PTFE prosthesis. The fenestrated stent graft was advanced through the left femoral artery and deployed with the device fenestration located at the bifurcation of the brachiocephalic artery. Then, a branched stent graft was deployed through the right common carotid artery in a retrograde manner between the brachiocephalic artery and the ascending aorta through the fenestration to complete the procedure. The patient had an uneventful postoperative course. Six months postoperative CT showed only a small, dissected lumen in the aorta around the left renal artery, and the dissected lumen had regressed to a thrombosed lumen. The current technique is easy to prepare, minimally invasive as an additional treatment with no risk of retrograde dissection.