Baylor University Medical Center Proceedings July 2017 - 299

a

b

c
Figure 2. Initial deployment of the stent with incomplete coverage and a type 1
endoleak.

against the aortic wall, which caused a late distal type 1 endoleak
(Figure 2).
The GORE C-TAG stent graft is designed to deploy the distal
and proximal end simultaneously by pulling two strings twisted
together into one pull mechanism (Figure 3a). This mechanism
can be untwisted and the proximal and distal side of the graft
tested to determine which string controls the proximal or distal
end by tugging a loop of the deployment string on the graft (Figure 3b). To improve the ability to land the stent graft precisely, a
45 mm × 15 cm stent graft was deployed in a selective manner
by separating the two pull strings at the deployment knob and
initially deploying the proximal aspect of the stent graft, followed
by adjusting the positioning of the stent graft by pushing up on
the control end of the delivery catheter, and then deploying the
distal portion of the stent graft by pulling the second deployment
string (Figures 3c, 3d). Thus, the distal fenestration was sealed oﬀ
the previously identiﬁed late type 1 endoleak without having to
extend the stent graft further down the aorta.
The postdeployment angiogram revealed complete exclusion
of the thoracic aortic dissecting aneurysm. A CT angiogram
of the chest performed on postoperative day 10 also showed
the stent graft to be in good position without an endoleak
(Figure 4). The patient survived to discharge but later succumbed to comorbidities unrelated to the aneurysm.
DISCUSSION
An endoleak, ﬁrst described by White (3), is a dreaded complication that, if left untreated, places the patient at risk for
aortic rupture, hemorrhage, and death. A type 1 endoleak is
deﬁned as ﬂow into the aneurysm sac either from the proximal
attachment zone (1A) or distal attachment zone (1B). A type 1
endoleak is a clear failure of the graft to occlude blood ﬂow
from the aneurysm sac, which would allow the aneurysm sac
to continually be pressurized, risking rupture. When recognized
it should be addressed immediately.
Type 1 endoleaks are commonly associated with anatomical variations such as aortic aneurysm angulation and short
July 2017

d

Figure 3. The "Parachute technique" of separating deployment strings and thus
selectively deploying the distal end of the GORE C-TAG stent graft to manage
aortic angulation: (a) twisted double string pull string and corresponding loops;
(b) test of which string pulls the distal end by tugging one end; (c) selective
deployment of proximal end; and (d) complete deployment.

attachment zone length, which can lead to technical diﬃculty in
eﬀectively landing a graft over the leak. In our patient, the distal
fenestration allowing blood ﬂow to pressurize the aneurysm
sac in a retrograde fashion had an angled anatomical variation.
Simultaneous deployment of the proximal and distal ends of
the GORE C-TAG stent graft was not allowing for angulation
of the graft necessary to cover the leak. By extending the graft
distally and angulating the graft to lay in tight apposition with

Novel technique of selective stent deployment in complicated thoracic aortic aneurysm

299
Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings July 2017
