CASE REPORT

A 74-year-old man was transferred from an outside hospital to our center with complaints of a sudden onset of severe pain between the shoulder blades. He was hemodynamically stable with a systolic blood pressure of > 180 mm Hg. An urgently performed CT scan including very late–phase imaging revealed an intramural hematoma (IMH) extending from the origin of the left subclavian artery (LSA) to the level of the celiac trunk without any further complications.

His past medical history included stage 3 chronic obstructive pulmonary disease, hypertension, and an open aortic repair with a bifurcated graft for a large abdominal aortic aneurysm (AAA) 6 years earlier. Furthermore, he was known to have a thoracic aortic aneurysm (TAA) that was approximately 57 mm in diameter, which was closely monitored over the recent years and showed minimal growth. 

The patient was treated with continuous ß-blocker infusion (labetalol) with rapid normalization of blood pressure to approximately 120 mm Hg systolic and relief of all pain symptoms. An urgent TEVAR was considered but due to the lack of healthy proximal (Figure 1) and distal sealing zones, the presumed high risk of paraplegia, as well as his favorable response to antihypertensive treatment, a conservative approach was chosen.

Images on a repeat CTA after 10 days were unchanged, and the patient was discharged in good condition. Further CTA imaging 1 month after presentation showed no further aortic dilatation and clear resolution of the thickness and extent of the IMH. Further optimization of medical treatment of cardiovascular risk factors was established during outpatient visits.

Six months after onset of his IMH, he returned for a scheduled follow-up visit including new imaging that showed almost complete resolution of the IMH (Figure 2) and a slight increase in maximum diameter to 59 mm. He was discussed in our aortic group again, and the decision was made to continue following a conservative strategy up to a maximum diameter of > 60 mm, as his risk of paraplegia was presumed to be far above average due to the extensive coverage of the thoracic aorta by TEVAR, in addition to his former open AAA repair. 

CTA 6 months later showed further dilatation of the TAA to 63 mm, and the decision was made to offer minimally invasive treatment by TEVAR. Due to his specific anatomy, a graft with optimal deployment precision was necessary, especially distally, as deployment of the graft close to the origin of the celiac trunk in order to maximize the distal sealing zone was presumed essential. For this purpose, the new GORE TAG Conformable Thoracic Stent Graft with ACTIVE CONTROL System seemed to be the ideal device. 

First, a spinal drain was inserted for neuroprotection, after which the patient was placed under general anesthesia. Through open access, a 24 Fr GORE® DrySeal Flex Introducer Sheath was placed through the right common femoral artery. The proximal GORE TAG Conformable Device (40 mm diameter, 200 mm length; with 15%–20% oversizing) was inserted up to the level of the distal arch, and a pigtail catheter was placed into the ascending aorta through the same sheath. After digital subtraction angiography (DSA) with the image intensifier at 45° left anterior oblique, the proximal device was deployed, aiming just distal to the LSA (length of proximal landing, 35 mm). The GORE TAG Conformable Device deployed exactly at the intended position, with no change in position during the different deployment steps (Figure 3).

The distal device (40 mm diameter, 200 mm length) was then inserted, and DSA was performed with the image intensifier at 50° right anterior oblique for optimal visualization of the origin of the celiac trunk. Deployment followed the intuitive steps, and again, perfect placement of the GORE TAG Conformable Device was achieved, this time aiming the distal part of the stent graft in order to be as close as possible to the celiac trunk (Figure 4; Videos 1 and 2). The intervention lasted < 90 minutes, and the patient recovered uneventfully with full neurologic function. Postoperative CTA showed complete exclusion of the TAA with optimal coverage of available proximal and distal landing zones (Figure 5).

DISCUSSION

The GORE TAG Conformable Thoracic Stent Graft with ACTIVE CONTROL System includes several unique features that contributed to the successful treatment of this patient. First, the nested handle design of the deployment system remained very easy to use despite the increased number of steps for staged deployment and angulation. Given our success with the straightforward deployment of the existing Conformable GORE® TAG® Thoracic Endoprosthesis, we wondered whether the added steps and functionality of the new device would complicate the deployment process, as more steps would have to be remembered. However, we found the operative steps to be exceptionally easy and intuitive with absolute ease of mind during the procedure.