Emergency Nightmares - Rupture of Type III Thoracoabdominal Aneurysm

Introduction The rupture of thoracoabdominal aneurysms (rTAA) represents one of the major challenges to the vascular surgeon. Recent developments in the endovascular armamentarium and the high mortality from open surgery make endovascular treatment an attractive option. Devices to be used in an emergency environment should be "off-the-shelf" and include, among others, EVAR snorkel/chimney and branched endoprosthesis (T-branch, Cook®).

We describe the case of a 70-year-old patient who was admitted to the emergency room due continuous low back pain with 3 days of evolution.

The tomographic computer angiography showed a type III thoracoabdominal aneurysm, with a transverse maximum diameter of 75x81mm in the infrarenal aorta and an exuberant hematoma in the left retroperitoneum, but no active extravasation of the contrast was observed (Figure 1). There was still marked tortuosity and moderate iliac calcification. It was decided to place a branched endoprosthesis (34 mm diameter at the top and 18 mm at the bottom). The branched endoprosthesis was extra-corporeally oriented, and introduced through a right femoral approach. The final position was verified with the digital subtraction angiography in anteroposterior incidence, ensuring that the distal border of each branch was 1.5 to 2 cm above the target vessel and that the stent marks presented the desired position. After the endoprosthesis was opened, the branches are catheterized by the left axillary access, however, it was verified that the endoprosthesis had an antero-posteriorly inverted implantation. It was possible to catheterize the superior mesenteric artery and the left renal artery (celiac trunk occlusion was documented intraoperatively); occlusion of the remaining endoprosthesis branches was performed with an Amplatzer. The patient evolved with multiorgan dysfunction and died at 24 hours post-operatively.

Implantation of an off-the-shelf branched endoprosthesis requires specific anatomical criteria such as aortic diameter> 25mm to allow catheterization of the vessels, the possibility of incorporating each target vessel at a 90o angle in relation to each branch and visceral arteries with a diameter between 4 and 8 mm. Anatomy review is important to understand the lengths and positions of the branches. It should be borne in mind that it is possible that the device might have to be rotated during implantation to better align the marks and that both incidences (anteroposterior and profile) may be useful in confirming the position, something that should be thoroughly pursued to safeguard a correct implantation regardless of the initial stent position in your delivery system.