International Society For Minimally Invasive Cardiothoracic Surgery

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Thoracic Endovascular Aortic Aneurysm Repair With Parallel Grafting (snorkel Sandwich Technique) Of The Celiac And Superior Mesenteric Artery
Saira Nisar, MBBS, MS, Vinod H. Thourani, MD, Christian C. Shults, MD.
MedStar Washington Hospital Center, Washington DC, DC, USA.

OBJECTIVE: Treatment of thoracoabdominal aortic aneurysms in high or extreme risk patients requires the use of creative endovascular techniques. We herein describe the use of parallel grafts and the snorkel sandwich technique to treat a thoracic aneurysm that had progressed to the visceral segment.
METHODS: An 82-year-old male initially presented to an outside hospital with a 5.5cm thoracic aortic aneurysm and was treated with TEVAR. He later developed a focal dissection at the distal end requiring extension of the TEVAR and a celiac stent. He presented to our institution with progressive distal dilation and aneurysm involving the celiac artery and the SMA. Due to age, COPD and frailty the patient was extreme-risk for open surgery.He underwent endovascular repair with proximal extension of celiac stent into the prior thoracic stent (TS) and distal extension of the TS to just above the superior mesenteric artery (SMA) resulting in snorkel sandwich. SMA stents were placed and extended proximally in the prior TS, and additional TS was deployed distally covering the SMA and ending just above the renal arteries.
RESULTS: The result was a snorkel (parallel graft)/sandwich (lying between two main body grafts) of celiac and the SMA that sealed the aneurysm while preserving flow to the celiac, SMA and the renal arteries. The patient recovered and was discharged home on post-operative day-3. One-month follow-up CT scan showed small gutter leak and decreases aneurysm size. He will undergo a CT angiogram in 3 months, if the aneurysm continues to shrink no intervention will be undertaken, if the aneurysm is the same size or larger, the gutter will be coiled.
CONCLUSIONS: Treatment of thoracoabdominal aortic aneruysms in high-risk patients can be successfully performed using the parallel grafting (snorkel/sandwich) technique.

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