case_images: PMC11636019_01
case_images: Preoperative CT scan of the patient after all the failed endovascular procedures. (a) TAAA 3D volume rendering after multiple endovascular procedures. (b) Axial view of overlapping of the thoracic endoprosthesis without any endoleak at this level. (c) Axial view showing the presence of type 2 Endoleaks with an increase of the diameter of the TAAA. (d) Axial view of the TAAA showing the largest diameter of the aneurysm, patent false lumen, and the CT stent. (e) Axial view that shows left renal stent and the reperfusion at this level (white arrow). (f) Dissection flap of the distal aorta (red arrow).
case_images: 10.1177_15385744241285112-fig1.jpg
case_images: PMC11636019_01_10.1177_15385744241285112-fig1.jpg
case_images: fig1-15385744241285112
case_images: His pre-operative CTA (Figure 1) showed a TAAA with a maximum diameter of 68 mm, multiple sources of reperfusion at the level of celiac trunk stent and left renal artery stent, and the presence of a dissection flap that continues down to the aorto-iliac bifurcation for a total cranio-caudal extension of approximately 8 cm.
case_images: Open repair of TAAA. (a) Exposition of the TAAA using an access through the 6th intercostal space. (b) Partial excision of the thoracoabdominal part of the aortic endograft. (white asterisk) (c) Carefully excision of the CT stent. (white arrow) (d) Final intraoperative result after replacement of the thoraco-abdominal aorta with a 30-mm multi-branched "Coselli" aortic graft (Vascutek, Renfrewshire, Scotland, UK) with an anterior view of the LRA reimplantation.
case_images: 10.1177_15385744241285112-fig2.jpg
case_images: PMC11636019_01_10.1177_15385744241285112-fig2.jpg
case_images: fig2-15385744241285112
case_images: Using a 30-mm multi-branched "Coselli" aortic graft (Vascutek, Renfrewshire, Scotland, UK), the descending thoracic aorta and the abdominal aorta were replaced, with excision of the visceral portion of the previous custom-made endograft, left renal artery and celiac trunk stents and the reno-visceral arteries anastomosed to the graft branches using perfusion technique to the target vessels with cold (4 ) histidine-tryptophan-ketoglutarate solution (Custodiol) for renal arteries and hematic perfusion for visceral arteries (Figure 2).
case_images: Cryoablation of the intercostal nerves for the post-operative pain control. The cryoablation site was chosen two intercostal nerves above and two below 6th intercostal space, which was the one chose for the thoracotomy incision. Needle electroneurography was used to monitor the efficacy of regional nerve block secondary to cryoablation. Stimulating electrodes were inserted in the intercostal space just below the lower costal margin following the course of the intercostal nerve, proximal to the point where cryoablation was planned. (a) Intercostal nerve cryoablation during the minimum temperature reached. (a) Compound muscle action potential during the intercostal nerve cryoablation. Note the fall of the amplitude at the beginning of each cycle as the seconds progress.(b) The AtriCure cryoablation system was used (AtriCure Inc, Mason, OH, USA).
case_images: 10.1177_15385744241285112-fig3.jpg
case_images: PMC11636019_01_10.1177_15385744241285112-fig3.jpg
case_images: fig3-15385744241285112
case_images: Before the closure, the patient received cryoablation therapy of T4-T8 intercostal nerves for post-operative pain management (Figure 3).  
case_images: Follow-up CT scan showing good results of TAAA open repair with partial excision of the thoracoabdominal endograft, bypass with a 30-mm multi-branched "Coselli" aortic graft (Vascutek, Renfrewshire, Scotland, UK) and patency of all visceral vessels bypasses and no pathological findings at the level of the thoracic endografts and anastomosis.
case_images: 10.1177_15385744241285112-fig4.jpg
case_images: PMC11636019_01_10.1177_15385744241285112-fig4.jpg
case_images: fig4-15385744241285112
case_images: After 6 months of the surgery the patient is alive and fully functional in his daily activities without any impairments and the CT scan showed good results of open surgery with patency of all visceral vessels and did not reveal any aortic pathological finding (Figure 4).