An 87-year-old Caucasian man presented to our institution with chest and epigastric pain radiating to his back. Computed tomographic scans were performed urgently, and these showed a large Crawford type I thoracoabdominal aortic aneurysm (Figure 1). The aneurysm measured 17 cm in length and was 5 cm to 6 cm distal from the left subclavian artery and 2 cm to 3 cm proximal to the celiac axis. The maximum anteroposterior diameter of the aneurysm was 13 cm above the diaphragm. The aorta between the celiac axis and the renal arteries was of normal size. Another aneurysm measuring 6 cm in length and 4 cm in diameter with no extension to the iliac arteries was detected distal to the renal arteries.
Our patient was not in a fit condition to undergo open surgery, so endovascular surgery was the preferred option. The diameters of the proximal and distal necks of the aneurysm were 3.2 cm and 3.4 cm, and a large mural thrombosis was present along all its length. We decided to treat our patient with a single tube stent graft. Although a long segment of the aorta would be covered during the procedure, we considered that there was a low chance of spinal ischemia, as the mural thrombosis had plugged all of his intercostal and lumbar arteries. Cerebrospinal fluid drainage was considered as a protective move for spinal circulation during the procedure.
Under general anesthesia, our patient's right femoral artery was dissected and controlled. An endovascular stent graft (VALIANT TF 4242C200X, Medtronic) was deployed distal to the left subclavian artery, thus covering the aneurysm. The stent graft was 21 cm in length and was placed just above his celiac axis. We controlled the proximal end deployment by real-time transesophageal echocardiography, and the distal end deployment under angiography. Follow-up transesophageal echocardiography, computed tomography and angiography showed a complete exclusion of the thoracoabdominal aneurysm (Figure 2). Correction of the abdominal aortic aneurysm was programmed for later. The patient was discharged three days after the procedure and showed no complications during the succeeding nine months.