Endovascular repair of a native postcoarctation thoracic aortic aneurysm.

A 75-year-old woman was referred to our vascular unit for endovascular repair of a postcoarctation thoracic aortic aneurysm. The patient was receiving antihypertensive therapy with four drugs but had presented with several episodes of hypertensive crisis. Other comorbidities included aortic valve insufficiency, left ventricle hypertrophy, thoracic kyphosis and scoliosis, and symptomatic asthma. Aortic imaging with three-dimensional multiplanar computed tomography angiography showed a 65-mm descending thoracic aortic aneurysm. The thoracic aorta presented significant tortuosity. The coarctation lumen diameter was 8 mm (A). Endovascular technical decision making was challenging due to the unknown resistance of the postcoarctation aneurysmal aortic wall to balloon dilatation. The patient was placed under general anesthesia. Open vascular access was performed through the right common femoral and right brachial arteries and percutaneous access through the left common femoral artery. The aortic coarctation was catheterized from the right brachial access, and a 300-cm 0.035-inch ultrastiff guidewire was used to cross the coarctation in a through-and-through fashion to permit the device to pass through the aortic tortuosity. After injection of 5000 IU of heparin, a Gore TAG endograft (W. L. Gore & Associates, Flagstaff, Ariz) was deployed, with a spontaneous increase of the coarctation diameter (B and C). A second device was distally deployed 5 cm above the celiac trunk. A Gore Trilobe balloon catheter was used to seal the overlapping zone between both stent grafts and the distal landing zone. Completion angiograms showed no type I endoleaks. No proximal ballooning was performed because invasive blood pressure monitoring stated a 20% gradient. The patient’s postoperative period was uneventful. Her blood pressure stabilized with therapy with two drugs. Computed tomography imaging after 9 months showed no restenosis and aneurysm exclusion (D).