Fenestrated aortic arch stent-graft malfunction with endovascular salvage

To describe a case of a fenestrated aortic stent-graft device malfunction in the aortic arch, which left the stent-graft deployed and almost irretrievable had it not been for an escalating series of endovascular salvage maneuvers.

A 47-year-old man presented with a rapidly enlarging 6.9-cm thoracic aneurysm that was a complication of a chronic type B aortic dissection. A 2-piece, custom-made, tapered, fenestrated thoracic endoprosthesis (innominate scallop plus single carotid) was planned to seal from the innominate origin to immediately above the celiac axis after staged left carotid to subclavian bypass. Blood pressure control with rapid ventricular pacing aided deployment of the proximal, fenestrated stent-graft component with both openings accurately positioned over their respective branch vessel ostia. Attempted retrieval of the nosecone was hampered by a release failure of the single conformance tie that connects the stent-graft to its central cannula. This left the stent-graft fully deployed with the nosecone irretrievable beyond a point immediately distal to the small fenestration. A series of endovascular salvage maneuvers ensued, ranging from simple actions to manipulate and balloon dilate the graft through to more complex attempts to break the tie and lasso the nosecone using snares. Finally, attempts at antegrade retrieval of the nosecone straightened the device and released the offending tie, allowing case completion.

This is a rare but cautionary example of the potential pitfalls of translating endograft technology from the abdominal aorta to the hostile environment of the aortic arch. It is likely that a combination of the arch curvature and hemodynamic forces, combined with the narrowed true lumen, contributed to failure of the trigger-wire tie release mechanism. Consideration of these endovascular salvage maneuvers may benefit interventional specialists who treat such diseases of the aortic arch.