A 76-year-old woman, who had previously undergone trans-thoracoabdominal esophagectomy with gastric tube reconstruction, was admitted for aspiration pneumonia. An impending rupture of AAA was suspected based on enhanced computed tomography (CT) findings; therefore, she was referred to our department. The AAA was located 5 mm below the left RA, with the aetiology being a pseudoaneurysm, and was enlarged only toward the right side, measuring 87 x 39 mm (Fig. 1A, Supplement Fig. 1). No signs associated with AAA rupture were present. Thus, the patient was diagnosed with a JRAAA.
Initially, GR was planned. However, the operative risk was estimated to be high because of past trans-thoracoabdominal esophagectomy and frail condition, with a body weight of 35 kg. Anatomical findings showed that the diameter of the thoracoabdominal aorta between the celiac artery (CA) and RA ranged from 21 to 23 mm, with over 50 mm available for the proximal landing zone. Thus, we planned CEVAR with three chimney endografts.
After general anaesthesia, 7-Fr long sheaths were inserted into the SMA and bilateral RAs through the exposed bilateral axillary arteries. A 7-mm endograft (VIABAHN, W.L. Gore and Associates, Inc., USA) and two 5-mm endografts (VIABAHN) were inserted into the SMA and bilateral Ras, respectively, via each sheath. Subsequently, EVAR was performed by using a 26-mm stent graft (Excluder 26-12-140, W.L. Gore and Associates, Inc., USA) and contra-lateral leg endograft (Excluder 12–100). The proximal extension device (aorta extension 28.5–33, W.L. Gore and Associates) was deployed from under the CA. After the deployment of all chimney endografts in the appropriate positions, ballooning to the main device and chimney endografts were performed simultaneously. The aortography showed no endoleaks. The total operative time was 259 minutes. The patient was discharged uneventfully on postoperative day 8. Postoperative CT showed preservation of visceral circulation, without endoleaks (Fig. 1B).