Management of a Left Common Carotid Artery Aneurysm by Double Branched Endovascular Arch Replacement Using Tandem Thoracic Branch Endoprosthesis Deployments.

Introduction: Branched thoracic endovascular aneurysm repair has become an increasingly common intervention since the advent of custom made and now off the shelf devices. This report describes the use of a sequential double deployment of the Gore TAG Thoracic Branch Endoprosthesis (TBE; WL Gore and Associates, Flagstaff, AZ, USA) to exclude a left common carotid artery aneurysm (LCCAA) due to large vessel vasculitis (LVV). Report: A 39 year old man (smoker, schizophrenic, known antiphospholipid syndrome, and previous deep vein thromboses) presented with a 45 mm LCCAA eight months after resection of a left carotid bulb aneurysm (using a reversed great saphenous vein, which had later occluded). Special investigations and multidisciplinary discussion highlighted the suspicion of LVV involving the arch outflow, and thus an endovascular treatment approach was selected. Sequential dual TBE devices were deployed for branch thoracic endovascular aneurysm repair from Ishimaru zone 3 to zone 0C with coil embolisation of the LCCAA. Successful exclusion of the LCCAA and maintenance of arch branch patency were achieved. Following referral to a tertiary rheumatology centre, the post-operative phase was particularly complicated by a haemorrhagic stroke, which was successfully treated by neurosurgical intervention. The patient continues to be stable at four months and is maintained on long term immunosuppressant, antiplatelet, lipid lowering, and anticoagulant therapy. Discussion: The use of an off the shelf device like the TBE allows modular totally endovascular arch reconstruction, facilitated here by the permissive effect of the left carotid outflow already being sacrificed. Endovascular options may provide an initial solution for treating aortic arch branch vessel aneurysms, thus reducing the morbidity and mortality of open surgical arch reconstructions, but an overall multidisciplinary approach is mandated for the management of such patients with long term follow up.