Schematic of branched endovascular aortic arch repair after previous type A dissection.
Central Message.
Incomplete expansion of a branched aortic arch endograft after previous type A dissection repair may cause branch crowding and functional pseudo-coartation and require open surgical conversion.
Institutional review board/ethics review board approval was not required, in accordance with our institutional policy. Written informed consent was obtained from the patient for publication of this case report. A 72-year-old man underwent emergency surgery for acute type A aortic dissection in 2021 with ascending aorta and hemiarch replacement. During follow-up, progressive thoracoabdominal aortic dilatation was observed, associated with persistent distal false lumen (FL) perfusion and concomitant infrarenal aortoiliac aneurysmal disease. The case was evaluated by a multidisciplinary aortic team. Open total arch replacement was considered the standard definitive treatment; however, the patient declined open surgery. A patient-tailored endovascular strategy was therefore selected in accordance with the patient’s preference and overall clinical condition.
In April 2024, a custom-made Relay branched arch endograft (Terumo Aortic) was implanted through bilateral femoral and common carotid access. The device included a proximal arch stent graft (34 mm diameter) with 3 inner branches (2 antegrade supra-aortic branches and 1 retrograde left subclavian branch). Completion angiography showed incomplete expansion of the graft within the arch with persistent FL perfusion.
During follow-up, the patient developed severe upper-body hypertension with a systolic pressure gradient exceeding 80 mm Hg between the upper limbs and between the right arm and lower extremities. Computed tomography angiography showed incomplete endograft expansion along the inner arch curvature at the level of the unsupported window segment, with graft infolding and luminal narrowing. Crowding of the 3 inner branches further reduced the effective lumen while the arch FL remain patent.
Refractory proximal hypertension with documented intragraft obstruction prompted open surgical conversion was indicated. Invasive pressure measurements confirmed a peak systolic gradient of approximately 80 mm Hg across the intraprosthetic segment, consistent with functional pseudo-coarctation.
Surgical Technique
Cardiopulmonary bypass was established through right axillary artery and femoral venous cannulation. The supra-aortic vessels were exposed and controlled distal to the bridging stents.
Circulatory arrest was instituted at 25 °C under antegrade cerebral perfusion. Explantation of the branched endograft from the previous hemiarch graft was technically demanding. The innominate bridging stent was removed, whereas the left carotid bridging stent was transected. The distal aorta was prepared in zone 2, and the endograft was divided flush with the vessel.
At the distal anastomotic collar, prosthetic material and dissected aortic layers, including the patent FL, were reapproximated in a sandwich configuration reinforced with Teflon felt.
Arch reconstruction was completed using a 28-mm Plexus multibranched graft (Terumo Aortic) interposed between the previous hemiarch graft and the distal collar in zone 2. Circulatory arrest time was 33 minutes and cardiopulmonary bypass time 164 minutes (Video 1).
The patient was extubated 6 hours postoperatively and transferred from the intensive care unit on postoperative day 2. The postoperative course was uneventful.
Predischarge computed tomography angiography demonstrated satisfactory arch reconstruction with appropriate graft configuration and incorporation of the distal endograft segment. The FL appeared thrombosed up to the mid-descending thoracic aorta, with distal reentry sites maintaining limited residual perfusion. No residual aortic obstruction was observed and the hemodynamic gradient resolved completely. The patient was discharged in stable condition.
Discussion
Branched aortic arch endografts have emerged as a promising option for patients who are unsuitable for open arch repair, with encouraging early-term and mid-term results reported.1,2 However, anatomical suitability remains limited, and interactions between device design and arch geometry may affect deployment and long-term durability.3
This case illustrates that branched arch endografts implanted after previous acute type A aortic dissection repair may interact unpredictably with reconstructed aortic anatomy, even when recommended implantation criteria are respected.4 In this case, incomplete expansion of the endograft reduced the effective luminal diameter and caused crowding of the inner branches directed to the innominate and left common carotid arteries, resulting in functional intragraft obstruction resembling pseudo-coarctation. To our knowledge, this is the first reported explantation of this device configuration for functional intragraft obstruction.
The precise mechanism responsible for device failure remains multifactorial. Although the endograft was deployed according to the preoperative plan within the previous ascending/hemiarch prosthetic graft, the interaction between the branched device and the reconstructed postdissection arch anatomy may have contributed to incomplete expansion.
Incomplete expansion may result from a complex interaction between device design and patient-specific anatomy. The noncircumferential “window” segment at the level of the inner branches may reduce radial support along the inner arch curvature, particularly in previously reconstructed arches. In addition, the circumferential Teflon reinforcement at the distal anastomosis of the previous hemiarch repair may have acted as a rigid constraint, limiting symmetric expansion of the proximal stent rings.
These observations suggest that the interaction between device design, arch geometry, and the mechanical properties of previous surgical reconstructions should be carefully considered when planning branched arch endografting in patients with previous type A dissection repair.5
Interestingly, within weeks after this case, we encountered a second patient treated with a similar endovascular device who required open conversion for a proximal type IA endoleak caused by infolding of the proximal stent crown. Despite different mechanisms, both required surgical correction.
Alternative endovascular corrective strategies, including aggressive balloon remodeling or relining techniques, may be considered in selected patients presenting with incomplete device expansion. In the present case, however, persistent FL perfusion, severe intragraft obstruction and concerns regarding the durability of a secondary endovascular correction favored open surgical conversion.
Overall, these observations highlight that branched arch endografts may interact unpredictably with reconstructed post-type A anatomy and emphasize that incomplete endograft expansion at the time of deployment should not be considered a benign or self-limiting phenomenon, as it may persist or progress over time and result in clinically significant functional obstruction requiring open surgical correction.
Conflict of Interest Statement
The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Supplementary Data
Surgical explantation of a branched aortic arch endograft with functional pseudo-coarctation after previous type A aortic dissection repair. The video demonstrates explantation of the branched endograft from the previous hemiarch graft, preparation of the distal aorta in zone 2, and arch reconstruction using a multibranched graft with incorporation of the retained endograft segment. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00381-0/fulltext.
References
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Associated Data
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Supplementary Materials
Surgical explantation of a branched aortic arch endograft with functional pseudo-coarctation after previous type A aortic dissection repair. The video demonstrates explantation of the branched endograft from the previous hemiarch graft, preparation of the distal aorta in zone 2, and arch reconstruction using a multibranched graft with incorporation of the retained endograft segment. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00381-0/fulltext.