Bailed out by TEVAR in a horrendous bleeding aortic arch cannulation site

Thoracic Endovascular Aortic Repair [TEVAR] is used as a gold standard treatment for aortic disease such as Type B dissection, proximal descending thoracic aortic disruption and descending thoracic aortic fistulas. There was never a report, before this one, of TEVAR utilization for uncontrolled bleeding on the aortic arch cannulation site.

This case report is of a 72-year-old female patient who presented to our facility with a day history of anterior sharp pain and dyspnea. Clinical examination revealed a frail patient in distress with tachycardia, tachypnea and elevated blood pressure. The patient had an early diastolic murmur of aortic valve insufficiency. Blood investigations were all normal. Radiological investigations (chest X-ray and Computed Tomography scan) showed prominent ascending aorta, widening mediastinum and dissection affecting the ascending aorta and the root. The patient was optimized in ICU and underwent composite ascending aortic replacement with a stentless composite valve and Dacron graft. The aortic arch cannula site bled uncontrollably and was controlled with a TEVAR stent bypass, as a staged hybrid procedure.

The patient had a bovine arch type B configuration, which ensured that the left common carotid artery was not occluded, when deploying the TEVAR stent. However, due to inadequate landing zone three, the left subclavian artery was over-stented and further intentionally occluded with an endovascular occluder to prevent steal phenomenon.

TEVAR was a real bailout procedure in such situation. Its indication, as in this case report was never reported before; hence, it was an interesting case to write-on.