A 78-year-old man was admitted to our outpatient clinic because of dyspnea and back pain. He underwent an emergency total aortic arch replacement (TAR) by means of the homemade open stent graft installation for DeBakey type I acute aortic dissection 16 years before the clinic visit. Two years after the TAR, infra-renal abdominal aortic aneurysm was repaired with a 20-mm bifurcated Gelsoft graft (Vascutek Ltd., Inchinnan, United Kingdom), and 6 years after the open abdominal aortic repair, TEVAR using Zenith TX2 2P-38-202 (proximal) and 2P-32-140 (distal) (Cook Medical, IN, USA) was performed to treat descending aortic aneurysm, using the previous homemade open stent graft as a proximal landing zone. Seven years after the TEVAR, he underwent thoracoabdominal aortic replacement using a 24-mm Coselli thoracoabdominal graft (Vascutek Ltd., Inchinnan, United Kingdom) via a left lateral thoracotomy. This procedure was complicated by strikingly dense adhesions around the TAA near the diaphragm, resulting in a 40 mm long remnant native TAA. These adhesions are considered to be due to diffuse large B-cell lymphoma involving mesenteric and retroperitoneal lymph nodes, which was treated by surgery and chemotherapy 6 years before the TAAA repair. Although he remained well one year after the open repair for the TAAA, he presented to our clinic with dyspnea and back pain. He has medical history of hypertension and hyperlipidemia. He has no family history and psycho-social history. Enhanced computed tomography (CT) scan revealed type Ib endoleak and acute enlargement of the remnant native aorta around the distal end of the Zenith TX2 2P-32-140Fig.1a, 1b. He was found to have a significant S-type bend in thoracoabdominal native and aortic grafts, which was a result of the open repair for the TAAAFigure 1c, 1d. Laboratory tests suggested a white blood cell count of 4.800/µL, hemoglobin of 11.5 g/dL, a C-reactive protein level of 8.85 mg/dL (normal range < 0.14), creatine of 1.59 mg/dL, procalcitonin of 0.08 ng/mL (normal range < 0.5) and fibrin/fibrinogen degradation products (FDP) of 49.2 µg/mL (normal range < 10). Because of his frequent surgical history of aortic repair and dense adhesions around the remnant native aorta which was observed during the previous open TAAA repair, we chose to pursue an urgent TEVAR. Under general anesthesia, with endobronchial intubation and mechanical ventilation, redo surgical cut-down was made on the right common femoral artery. First, a 0.035-inch hydrophilic guidewire was inserted to the ascending aorta from the right femoral artery, following which a 65-cm 22 French introducer sheath (DrySeal; W.L. Gore & Associates, Flagstaff, AZ, USA) was inserted. But, due to the extremely sigmoid bend, we could not insert the 65-cm-long sheath even to the descending aorta. Therefore, the guidewire in the ascending aorta was snared by a EN Snare® Endovascular Snare System (Merit Medical System, South Jordan, UT, USA) from the right brachial arteryFigure 2a and the pull through was made. We snared the guide wire in the ascending aorta, considering the risk of embolization. Using this through-and-through wire technique, the long sheath was advanced until it was positioned 5 cm proximal to the distal end of the Zenith TX2 2P-32-140Figure 2b. A pull on the catheter was required to straighten the S-type shapeVideo1. A GORE TAG conformable stent graft with active control (CTAG with AC; diameter 37 mm, length 20 cm; W.L. Gore & Associates, Flagstaff, AZ, USA) was then advanced within the long sheath under fluoroscopic monitoring to the appropriate locationFigure 2c. The long sheath was withdrawn gentlyFigure 2d, and the stent graft was deployed. After that, a CTAG with AC (diameter 37 mm, length 10 cm) was advanced and deployed covering 4 cm of the distal end of the proximal CTAG with AC (diameter 37 mm, length 20 cm) and 4 cm of the proximal end of the previous TAA graft. There was no endoleak observed. The patient’s post-operative course was uneventful. Post-operative CT taken before discharge demonstrated no endoleak or embolic events. He is doing well 19 months after the surgery without any complications including neurological disfunction, and the aneurysm is shrunk. Laboratory tests suggested FDP of 32.2 µg/mL (normal range < 10).