Total endo‑aortic repair for a triple‑lumen post‑dissection TAAA

A previously dissected thoraco‑abdominal aorta has morphed into an aneurysm fed by two competing false lumens—each nurturing vital visceral branches—while a compressed true lumen precariously threads between them.

Objective: to protect all four visceral organs without open conversion.
Key words: triple‑lumen, physician‑modified fenestration, multi‑access strategy, staged hybrid repair.

Can an endovascular plan out‑smart such anatomic chaos?

Zhuang Hui

Xiamen University Affiliated Cardiovascular Hospital, China

Part I - Case presentation

Core topics

Chronic type‑A dissection & aneurysmal degeneration
Triple‑lumen morphology
Physician‑modified endografts
Multi‑access cannulation techniques
Staged versus one‑shot repair strategies
Visceral‑ischaemia risk mitigation (SCI, renal, mesenteric)

Clinical presentation

63‑year‑old man with progressive back discomfort and enlarging thoraco‑abdominal aneurysm.
Past interventions: 2 × TEVAR, 1 × open ascending repair, coil embolisation.
Symptoms: mild post‑prandial abdominal pain; creatinine 92  µmol/L; no spinal‑cord deficit.

A: CTA 3‑D render. B: True Lumen (Black). False Lumen 1 (Red) with right & left renal artery origins. False Lumen 2 (Blue) with celiac trunk (CT) & superior mesenteric artery (SMA) origins. Multiple re-entry tears throughout the thoracoabdominal segment.

Risk assessment

Anatomical: visceral supply entirely from FLs; prior grafts in thoracic aorta; compressed TL ≤ 6 mm; diameter 62 mm.
Physiological: Creatinine 92 µmol/L; prior thoracic incision increases open‑redo risk.
Neurological: extensive aortic coverage already → additive spinal‑cord ischaemia risk if full exclusion is attempted.
Operative history: adhesions around prior thoracic graft; hostile abdomen for visceral debranching.

Current treatment options

Redo open thoraco‑laparotomy with visceral re‑implantation.
Hybrid debranching (visceral bypass + distal stent‑graft).
Custom manufacturer‑built branched / fenestrated endograft (lead time  ≥  6 weeks).
Physician‑modified endograft tailored on‑table.
Conservative surveillance (risk of rupture >  15  % / yr).