Multimodal Endovascular Treatment of Post-Dissection Thoracoabdominal Aneurysm Using Adjunctive Advanced Endovascular Techniques Combined to Branched Repair: Case Report

Background and Clinical Significance: Treatment options for chronic type B aortic dissections (TBADs) remain a topic of ongoing debate. Patients with post-dissection thoracoabdominal aortic aneurysms (PD-TAAAs) are typically younger than those with degenerative TAAAs, and their aortas undergo continuous remodeling over their lifetime. Fenestrated/branched endovascular aortic repair (F/B-EVAR) has shown promising results, but it can be challenged by the presence of a narrow true lumen, which hinders navigation and deployment of bridging components. Moreover, the presence of patent segmental arteries originating from the false lumen may prevent aneurysm shrinkage due to persistent flow, which may also result in insufficient spinal cord protection strategies and an increased risk of spinal cord ischemia. Consequently, multiple endovascular interventions are often necessary to address the persistent anatomical changes in these patients. Case Presentation: We present the case of a patient affected by a post-dissecting TAAA who underwent multiple open and endovascular treatment attempts. The presence of prior multiple laparotomies discouraged a new open surgical repair, while the hypertrophic segmental arteries and the presence of a narrow true lumen made standard F/B-EVAR unfeasible. The patient was successfully treated using a combination of different adjunctive advanced endovascular techniques, including minimally invasive segmental artery coil embolization (MiSACE) as a spinal cord preconditioning strategy and prevention of type II endoleak. Moreover, transcatheter electrosurgical septotomy (TES) was used to create a single aortic channel in the presence of a narrow true lumen, which allowed the deployment of a multifeatured, custom-made branched endograft. Conclusions: Endovascular repair of post-dissection TAAAs requires a thorough understanding of advanced endovascular adjuncts, which are often combined to overcome the complex anatomical challenges inherent to this disease. Although encouraging results have been reported, both segmental artery embolization for the indications described here and TES warrant further evaluation in prospective multicenter studies to confirm their safety and efficacy.