Baylor University Medical Center Proceedings July 2017 - 298

Novel technique of selective stent deployment in
complicated thoracic aortic aneurysm
Allan Young, DO, Lauren Kastner, MD, and Javier Vasquez Jr., MD

A 72-year-old woman presented with a thoracic aortic aneurysm that was
found to have increased from 5.1 cm to 7.1 cm. Due to the increase in
size, the aortic aneurysm required endovascular repair. After deployment
of a GORE C-TAG stent graft, a distal type 1 endoleak was still present,
requiring deployment of another stent to achieve total coverage. The
aorta had an angled anatomical variation often associated with type
1 endoleaks causing technical difficulty with conventional deployment
of the graft. By employing a novel Parachute technique, the graft was
selectively deployed at the distal end, and the position was adjusted
to fit the angulation of the aorta, followed by selective deployment of
the proximal end. This selective deployment allowed for the adjustment
necessary to effectively cover the endoleak.

ortic aneurysms are a signiﬁcant contributor to morbidity and mortality in the United States, with an incidence of thoracic aneurysms estimated at 5.9 cases
per 100,000 person-years (1). Descending aortic aneurysms make up approximately 40% of all thoracic aneurysms
and should be repaired once they expand to 6.0 cm to avoid
the complication of aneurysm rupture. The ﬁrst thoracic endovascular aortic repair (TEVAR) was reported by Dake in
1994 (2), and since then, TEVAR has become the standard
of care due to its lower morbidity and mortality compared
with open repair. The aortic aneurysm anatomy is the most
important criterion in the ability to successfully repair these
aneurysms via an endovascular approach, and variations in
the individual's anatomy can cause technical diﬃculty with
deployment of grafts. Here we present a case in which diﬃcult
aortic anatomy led to a type 1B endoleak, which was managed
by a novel technique of selective graft deployment which we
call the Parachute technique.
CASE REPORT
A 72-year old woman with known hypertension, hyperlipidemia, chronic obstructive pulmonary disease, a chronic
type B aortic dissection (measuring 5.1 cm at time of diagnosis
5 years earlier), and an open abdominal aortic aneurysm repair
(10 years earlier) presented with dyspnea and chest pain. She
was initially diagnosed with recurrent pneumonia and sepsis,
and during workup, a computed tomography (CT) angiogram

298

Figure 1. The 7.1 cm thoracic aneurysm present before stenting.

of the chest conﬁrmed the type B aortic dissection. The diameter of the descending thoracic aorta had increased to 7.1 cm
(Figure 1) and was compressing pulmonary vasculature, thus
requiring repair.
In the operating room via percutaneous femoral artery access, an aortogram identiﬁed the proximal and distal fenestrations, and the appropriate origin vessels were marked. A GORE
TAG thoracic endoprosthesis stent graft device measuring 37
mm × 10 cm was deployed just distal to the oriﬁce of the left
subclavian artery followed by a 45 mm × 15 cm stent graft
distally. The postdeployment aortogram showed an excellent
proximal seal, but due to the tight stenosis and angulation in
the true lumen distally, the graft did not have ﬁrm apposition
From the Department of Vascular Surgery (Young, Vasquez) and the Department
of Surgery (Kastner), Baylor University Medical Center at Dallas.
Corresponding author: Allan Young, DO, Department of Vascular Surgery, Baylor
University Medical Center at Dallas, 3500 Gaston Avenue, Dallas, TX 75246
(e-mail: ayoung02@mymail.nyit.edu).
Proc (Bayl Univ Med Cent) 2017;30(3):298-300

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