Repair of type IV thoracoabdominal aneurysm with a combined endovascular and surgical approach

We report an unusual case of type IV thoracoabdominal aneurysm (TAA) with s uperior mesenteric artery (SMA), celiac artery, and bilateral renal artery aneurysms in a patient who underwent an earlier repair of two infrarenal ab dominal aortic aneurysm (AAA) ruptures. Because of the presence of the visc eral artery aneurysms and the earlier operation through the retroperitoneum , standard surgical treatment via a retroperitoneal approach with an inclus ion grafting technique was considered difficult. A combined surgical approa ch achieving retrograde perfusion of all four visceral vessels and endovasc ular grafting allowing exclusion of the TAA was accomplished. Complete excl usion of the aneurysm and normal perfusion of the patient's viscera was doc umented by means of follow-up examinations at 3 and 6 months. The repair of a type TV TAA with a combined endovascular and surgical approach (CESA) al lowed us to manage both the aortic and visceral aneurysms without thoracoto my or re-do retroperitoneal exposure and minimized visceral ischemia time. If the durability of this approach is confirmed, it may represent an attrac tive alternative in patients with aneurysmal involvement of the visceral se gment of the aorta.