Total Percutaneous Access for Deployment of a Custom Made Fenestrated Stent Graft in a 90 Year Old with a Large Symptomatic Thoracic Aortic Aneurysm

INTRODUCTION: Open surgical cut down has been the standard for gaining carotid access in most thoracic endovascular repairs of aortic aneurysm (TEVAR) cases; however, when suitable, total percutaneous repair can be beneficial. REPORT: A relatively fit 90 year old man with few medical comorbidities presented with six months of worsening upper back pain and an Ishimaru zone 2 fusiform thoracic aortic aneurysm of 7.2 cm diagnosed on CT aortography. A total percutaneously inserted custom made device (CMD) with innominate artery (IA) scallop, left common carotid artery (LCCA) fenestration combined with left subclavian artery (LSA) occlusion provided an effective repair. Haemostasis was obtained with Abbott Perclose ProGlide suture-mediated devices. The patient was discharged on post-operative day two. Follow up CT at one month was unremarkable without any endoleak, and an improvement in symptoms. DISCUSSION: There are risks of cerebral ischaemia and other complications with open carotid cut down, hence it is worth considering avoiding if possible, especially for select patients. Retrograde carotid access and subsequent closure device deployment is not new, but in conjunction with CMD, TEVAR allowing for carotid stenting is feasible and less often described in the literature.