Introduction: The suitability of the proximal and distal landing zones remains one of the main limitations to thoracic endovascular aortic repair. The advent of custom-made scalloped stent grafts widened the endovascular options in some challenging anatomies.
Methods: The authors present three cases of thoracic aortic aneurysm (TAA), with three different hostile anatomies, successfully treated with custom-made scalloped stent grafts.
Results: Case1: Male patient, 47 years old, no relevant medical history. Angio-CT revealed a 54mm post- traumatic TAA, extending distally from the origin of the left subclavian artery. Inadequate sealing in Ishimaru zone 2 was evident. The patient was sequentially treated by means of a carotid-subclavian bypass followed by TEVAR with proximal scallop to the left common carotid artery. Proper proximal sealing was obtained. Case2: Male patient, 76 years old, diagnosed with a 65mm diameter TAA, involving the origin of the left subclavian artery. Presence of a bovine trunk, and inadequate landing zone distally to it, were noted. The patient was sequentially treated by means of a carotid-subclavian bypass followed by TEVAR with proximal scallop to the bovine trunk. Proper sealing in Ishimaru zone 2 was granted. Case3: Male patient, 77 years old, multiple comorbidities. Angio-CT revealed a 59,3mm saccular aneurysm of the distal thoracic descending aorta, extending proximally from the origin of the celiac trunk. Good collateralization was observed after celiac trunk occlusion test. Proper distal seal was obtained by means of selective embolization of the celiac trunk followed by TEVAR with distal scallop to the superior mesenteric artery. All procedures were uneventful, with no reported endoleaks, birdbeaks, migrations or re- interventions. There are no reported complications at 1-year follow-up.
Conclusion: Custom-made scalloped thoracic stentgrafts are an accessible, reproducible and safe therapeutic option when dealing with hostile descending thoracic anatomies, and should be considered as a minimally-invasive effective solution in selected cases.