1. Abdelkader Almanfi, MD, MRCP-UK
Interventional cardiology Fellow
Texas Heart Institute

2. • Nothing to disclose related to this presentation
Disclosures

3. Clinical Presentation
• A 79-year-old male patient was referred to us by
cardiothoracic surgery for endovascular repair for
saccular aneurysm ATAA due to his risk comorbidities
Aortogram showed a
saccular ascending
thoracic aortic
aneurysm

4. o Initially, he was diagnosed with ATAA after he sustained
a cardiac arrest, ventricular fibrillation, he was
cardioverted by paramedics and was admitted to the
hospital
o He underwent Coronary Angiography which revealed no
evidence of CAD, Aortogram showed a saccular ATAA
o ICD was implanted for secondary prevention of SCD
o PMH: HTN, h/o SBE with Mitral regurgitation, atrial
fibrillation, cardiac arrest, ventricular fibrillation, recent
ICD obesity, MV repair

5. Our Plan
• Due to high surgical risk and comorbidities including
previous mitral surgery, recent cardiac arrest and the
anterior location of the aneurysm and close proximity to
the sternum, we decided to proceed with
“ endovascular repair of ascending aortic thoracic
aneurysm under local anesthesia, conscious
sedation, percutaneous approach with RV pacing ”

6. Procedural Technique
 The procedure was done in the endovascular suite
 Access :
 A percutaneous access using micropuncture technique
in both CFAs and 6 Fr sheaths were placed in the right
and left CFAs
 Venous access in the left CFV with 6 Fr Sheath, used for
temporary pacemaker of the RV  for rapid RV pacing
during deployment
 A 10 Fr Prostar device was used to preclose the right
CFA, and 6 Fr Proglide was used to preclose the left
CFA.

7. Prostar XL™ Technique

8. Aortic Angiogram

9.  From the Right CFA access, the aortic valve was
crossed using regular J wire and JR5 Catheter.
 The wire then was exchanged with .035” Lunderquist
that was positioned inside the LV cavity.
 Progressive dilatation of the ipsilateral side with 14, 16,
18 Fr sheaths was performed successfully.
 A 22 Fr. Medtronic sheath was placed with no
complications.

10. advancement &
positioning of a
(44 mm D x 80 mm L)
Valiant Medtronic stent
graft

11. First stent graft
deployed in the
ascending aorta

12. Second Valiant (44 mm x 80
mm length) stent graft
overlapped with first graft
Angiography after
deployment of the endograft
revealed a significant
foreshortening and
presence of small endoleak

13. Final angiogram
showing total
exclusion of the
aneurysm and
patency of coronary
and the Innominate
arteries.

14. Angiogram documenting
patency of the innominate
artery

15. Our patient had
uneventful post-op
course and was
discharged home next
morning

16. CTA after one month follow up

17. Learning points
 To the best of our knowledge, we are reporting the first
case of endovascular repair of ATAA under local
anesthesia, conscious sedation, percutaneous approach
with RV pacing.
 The current standard treatment of ATAA is the surgical
approach as endovascular repair is very challenging due
to the anatomical complexities including the origin of aortic
arch vessels, hemodynamic forces, respiratory motion,
angulation of the inner aortic curvature and proximity to
the coronary/Innominate arteries and the aortic valve.
 There are no specific devices designed and approved for
this purpose.

18. In our patient, a successful repair of ascending
aortic aneurysm has been performed under local
anesthesia, and that combination of TEVAR of
ascending aorta with local anesthesia &
conscious sedation is what makes this case
unprecedented and could be used in the future in
the appropriate settings as an alternative to more
invasive approaches.

20. Thank
you