Endovascular Repair of Ruptured Thoracoabdominal Aortic Aneurysm with an Off-the-shelf Endoprosthesis

Background: Thoracoabdominal aortic aneurysm type 3 (TAAA3) is a challenging disease to vascular surgeons. In these cases, the best treatment methodology is conventional surgery, which portends a mortality rate ranging from 8% to 25%. Endovascular treatment has been shown to be a good alternative, with encouraging results. In 2012, a new alternative for endovascular treatment of TAAA3 was presented: Cook T-Branch endoprosthesis (Cook Medical, Bloomington, Indiana). We present the first successful case of endovascular treatment of a ruptured TAAA3 with this stent.

Case report: A 68-year-old was admitted to the emergency department with epigastric pain, radiating to the back without improvement with opioids. Physical examination revealed an epigastric pulsatile mass without evidence of peritonitis or blows. The patient was known to have a thoracoabdominal aortic aneurysm. A computed tomography angiography showed growth of the abdominal aneurysm, accompanied with signs of rupture (fat blurring in the posterior region of TAAA3). The patient was submitted to endovascular repair of a ruptured TAAA3 in a hybrid operating room using a 34 × 18 × 202 mm T-Branch graft. It was an uneventful 330-min procedure under general anesthesia. Immediate postoperative period had no cardiovascular events. Evolution showed excellent distal perfusion and complete pain relief.

Conclusions: Until now, the only endovascular alternative for ruptured aortic aneurysm was the parallel prosthesis technique. The development of an off-the-shelf T-Branch prosthesis (Cook Medical) has solved this problem in many cases, enabling immediate treatment of this type of aneurysm in approximately 83% of patients. The fact that the thoracic aorta would be excluded lead the patient to a high risk of spinal cord ischemia. We therefore decided to make a cerebrospinal fluid drainage. There is no consensus regarding the best devices to be used as branches. In this case, we chose to use the previously described covered stents, according to its flexibility and compatibility with the length of arteries. This is the first report of the use of a T-branch (Cook Medical) for treatment of a ruptured TAAA3. The development of an off-the-shelf endoprosthesis has many advantages: it is available for use in an emergency situation, and there is no time lapse for its preparation. The T-Branch stent graft is a valid option for the treatment of ruptured TAAA3.