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Salvage of Endoluminal Exclusion of an Anastomotic Arch Aneurysm with a “Kissing” Carotid Stent
Salvage of Endoluminal Exclusion of an Anastomotic Arch Aneurysm with a “Kissing” Carotid Stent Mark K. Eskandari, MD, and Scott A. Resnick, MD Traditional open repair of thoracic aortic aneurysms remains a high-risk surgical procedure. Thoracic aneurysm stent-graft repair is evolving but has promise as a minimally invasive treatment option. Herein a case is presented of an anastomotic arch aneurysm treated with a custom-made thoracic stent-graft after a left subclavian artery–to– carotid artery transposition. Proximal extension for a type I endoleak necessitated a bailout procedure with a “kissing” left common carotid artery bare stent. J Vasc Interv Radiol 2004; 15:1317–1321 Abbreviations:
CCA ⫽ common carotid artery, SCA ⫽ subclavian artery
DESPITE advances in the surgical management of thoracic aneurysms, the morbidity and mortality rates associated with this operation remain alarmingly high (1,2). The evolution of endoluminal stent-graft repair for abdominal aortic aneurysms lends support to the application of this technique to thoracic aneurysms. Perceived benefits of this less-invasive procedure encompass a reduction in cardiac, pulmonary, renal, and neurologic complications. Specific circumstances that may warrant pursuit of this emerging technology include coexisting severe cardiopulmonary disease, acute dissection, or pseudoaneurysms. We present a case of an anastomotic aortic arch aneurysm repaired with a custom-made stent-graft
From the Division of Vascular Surgery (M.K.E.) and Section of Interventional Radiology (S.A.R.), Northwestern Memorial Hospital, Feinberg School of Medicine, Northwestern University, 201 East Huron Street, Suite 10-105, Chicago, Illinois 60611. Received April 27, 2004; revision requested June 17; revision received and accepted June 19. Address correspondence to M.K.E.; E-mail: [email protected] M.K.E. receives research support from W. L. Gore & Associates, Inc. and Cook, Inc., and serves as a consultant for Medtronic AVE, Guidant, and Cordis. S.A.R. has identified no conflicts of interest. © SIR, 2004 DOI: 10.1097/01.RVI.0000137405.46922.0F
after a left subclavian artery (SCA)–to– common carotid artery (CCA) transposition. Proximal extension for a type I endoleak resulted in coverage of the left common carotid artery managed with a “kissing” bare stent technique.
CASE REPORT A 68-year-old man with a symptomatic penetrating aortic ulcer in the proximal descending thoracic aorta had an open interposition Dacron graft repair 1 year before presentation. His medical history also included a remote aortobifemoral bypass graft. A surveillance computed tomography (CT) scan at 1 year demonstrated large pseudoaneurysms arising from the proximal and distal anastomotic sites (Fig 1) and a native aortic diameter of 30 mm. Angiography confirmed these findings and revealed nonvariant arch anatomy (Fig 2). Endoluminal repair of the pseudoaneurysm with a modular custom-made stent-graft system was recommended. The entire procedure was performed in an operating room angiography suite with a 15-inch image intensifier (Philips Medical Systems, Andover, MA) under general anesthesia. As a result of the short distance (5 mm) between the left SCA and the proximal pseudoaneurysm in the dis-
tal arch (“seal zone”), a standard left SCA/CCA transposition was performed, providing an additional 15 mm of sealing. Next, the right limb of the aortobifemoral graft was surgically exposed via a groin incision for subsequent delivery of the stent-graft system. The components of the modular graft were manufactured with use of 35-mm ⫻ 5-cm Gianturco Z stents (Cook, Bloomington, IN) covered with an ironed woven polyester fabric (Cooley Veri-soft Dacron; Meadox Medicals/Boston Scientific, Oakland, NJ) as originally described by Dake et al (3). The endografts were fashioned in 5-cm and 10-cm length systems and fully covered with Dacron. After the administration of systemic heparin, the right limb of the aortobifemoral graft was accessed and, over a stiff guide wire (Lunderquist wire; Cook), a 22-F ⫻ 60-cm length Teflon delivery sheath (Keller-Timmerman sheath; Cook) was positioned distal to the left CCA. This sheath was used for sequential delivery of the components in a proximal-to-distal orientation. During the time of deployment for each endograft, brief (10 –12 seconds) cardiac arrest was achieved with systemic administration of adenosine (4). After placement of two 10-cm-long components, an aortogram revealed continued filling of the proximal pseudoan-
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“Kissing” Carotid Stent Exclusion of an Anastomotic Arch Aneurysm
November 2004
JVIR
Figure 1. CT scans showing large pseudoaneurysms arising from the proximal and distal anastomotic sites. (a) Large black arrow, innominate artery; small black arrow, left common carotid artery; small white arrow, Dacron graft; large white arrow, proximal pseudoaneurysm. (b) Large black arrow, ascending aorta; white arrow, distal pseudoaneurysm; small black arrow, distal Dacron graft.
eurysm (Fig 3). The proximal type I endoleak was successfully sealed after placement of an additional 5-cm endograft, which also resulted in coverage of the left CCA orifice. This was rescued with retrograde cannulation of the left CCA via the open neck incision, followed by stent implantation of the left CCA orifice with a Genesis 8-mm ⫻ 39-mm stent (Cordis, Miami Lakes, FL) in a “kissing” configuration with the existing Gianturco-based Z stent-graft. The radial force of the Genesis stent was sufficient to displace the Z stent-graft away from the common carotid artery origin. Component overlap sites were “seated” with use of a compliant 27-mm balloon. The completion aortogram revealed total exclusion of the pseudoaneurysms and brisk filling of the left CCA and SCA/CCA transposition through the stent-implanted segment (Fig 4). The patient’s postoperative course was uneventful, and he was discharged home 3 days later and prescribed a regimen of aspirin and clopidogrel. CT at 6-month follow-up revealed complete exclusion of the pseudoaneurysms as well as patency of the left common carotid stent (Fig 5). This report was approved by the institutional review board at our institution.
Figure 2. Angiography confirming CT findings of pseudoaneurysms and revealing nonvariant arch anatomy. (a) Large white arrow, proximal pseudoaneurysm; small white arrow, Dacron repair; large black arrow, distal pseudoaneurysm; small black arrow, native aorta. (b) Large black arrow, distal pseudoaneurysm; small white arrow, neck of pseudoaneurysm; large white arrow, Dacron graft; small black arrow, descending thoracic aneurysm.
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Eskandari and Resnick
Figures 3, 4. (3) Aortogram after placement of two 10-cm-length components. Note continued filling of the proximal pseudoaneurysm. The white arrow indicates a subclavian carotid transposition; the black arrow indicates a type I endoleak. (4) Completion aortogram shows total exclusion of the pseudoaneurysms and brisk filling of the left CCA and SCA/CCA transposition through the stent-implanted segment. The black arrow indicates the left common carotid stent; the white arrow indicates the stent-graft.
DISCUSSION Conventional open repair of aortic arch anastomotic aneurysms is fraught with problems (1). The widespread use of endografts for the treatment of abdominal aortic aneurysms has fostered a significant interest in broadening its application to include the proximal aorta. Although an attractive concept, successful endoluminal exclusion of aortic arch aneurysms can be plagued by difficult arch anatomy and requires coverage of one or more of the great vessels to attain a sufficient seal zone for the stent-graft components (5). Published reports for endoluminal management of arch aneurysms are limited and most frequently bundled within an institutional experience of thoracic stentgraft repairs (6,7). For proximal descending or distal arch thoracic aneurysms, intentional coverage of the left SCA without bypass or with extraanatomic bypass of the great vessels to achieve a longer seal-zone has been used. These include left SCA/CCA transposition and right CCA/left CCA bypass. Un-
fortunately, such efforts may be precarious or impossible among patients with an existing left mammary-based coronary bypass or those with vertebral artery disease. When additional seal-zone length is needed up to the innominate artery despite an extraanatomic bypass, one group has used a modified, or “scalloped,” stent-graft (8). Other options include coil embolization and branched stent-graft repair (8 –11). In the case report by Chapot et al (10), 2-year follow-up after coil embolization of a saccular pseudoaneurysm with a small communication between the aortic lumen and the aneurysm showed no increase in sac size. Unfortunately, this intervention has limited application because many anastomotic aneurysms do not have small necks, as exemplified by our case. In addition, absence of flow does not guarantee long-term prevention of continued aneurysm growth as a result of endotension. Stent-graft repair appears to have a theoretic advantage over coiling because of complete exclusion of flow and transmitted pressure into the an-
•
1319
eurysm. The most notable example has been the report by Inoue et al (11). To date, to our knowledge, this is the only report of a successfully deployed unibody branched stent-graft used to treat an aortic arch aneurysm. More recently, Chuter et al (9) have reported results with use of a combination of a modular branched stent-graft after extraanatomic bypass for an arch aneurysm. Each of these reports provides new and innovative ways to deal with elective repair of aneurysms in various locations of the aortic arch. A unique feature of our report is the application of a bailout kissing stent technique for inadvertent coverage of a great vessel. The resultant coverage was primarily a result of the long rigid struts of the stents coupled with the sharp angulation of the aorta at the proximal sealzone site. Perhaps the use of shorter stents (ie, 2.5 mm vs 5.0 mm) would have better accommodated the angulated aorta in this case. The use of this particular salvage technique hopefully will not need to be incorporated into the revolutionized thoracic stentgrafts currently employed in ongoing clinical trials.
CONCLUSION Modular stent-graft repair of thoracic aneurysms is a feasible shortterm solution to the vexing problem of an anastomotic arch pseudoaneurysm. The kissing stent configuration described herein may allow for extended application of this technology in patients with a short proximal stent-graft landing zone. The long-term success compared with traditional open repair remains to be validated through ongoing clinical trails. References 1. Crawford ES, Svensson LG, Coselli JS, Safi HJ, Hess JR. Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch. Factors influencing survival in 717 patients. J Thorac Cardiovasc Surg 1989; 98:659 – 673. 2. Coselli JS, Conklin LD, LeMaire SA. Thoracoabdominal aortic aneurysm repair: Review and update on current strategies. Ann Thorac Surg 2002; 74(suppl):S1881–S1884. 3. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascu-
1320
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“Kissing” Carotid Stent Exclusion of an Anastomotic Arch Aneurysm
Figure 5. CT scan at 6-month follow-up shows complete exclusion of the pseudoaneurysms as well as patency of the left common carotid stent. (a) Large white arrow, left carotid stent; small white arrow, proximal stent graft; black arrow, thrombosed pseudoaneurysm. (b) White arrow, thrombosed pseudoaneurysm; black arrow, distal stent-graft. (c) Threedimensional reconstruction of the left common carotid stent.
November 2004
JVIR
Volume 15
Number 11
lar stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994; 331:1729 –1734. 4. Dorros G, Cohn JM. Adenosine-induced transient cardiac asystole enhances precise deployment of stentgrafts in the thoracic or abdominal aorta. J Endovasc Surg 1996; 3:270 –272. 5. Criado FJ, Clark NS, Barnatan MF. Stent graft repair in the aortic arch and descending thoracic aorta: a 4-year experience. J Vasc Surg 2002; 36:1121–1128. 6. Cambria RP, Brewster DC, Lauterbach SR, et al. Evolving experience with
Eskandari and Resnick
thoracic aortic stent graft repair. J Vasc Surg 2002; 35:1129 –1136. 7. Scharrer-Pamler R, Kotsis T, Kapfer X, Gorich J, Orend KH, Sunder-Plassmann L. Complications after endovascular treatment of thoracic aortic aneurysms. J Endovasc Ther 2003; 10: 711–718. 8. Kruger AJ, Holden AH, Hill AA. Endoluminal repair of a thoracic arch aneurysm using a scallop-edged stentgraft. J Endovasc Ther 2003; 10:936 – 939. 9. Chuter TA, Schneider DB, Reilly LM,
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Lobo EP, Messina LM. Modular branched stent graft for endovascular repair of aortic arch aneurysm and dissection. J Vasc Surg 2003; 38:859 – 863. 10. Chapot R, Aymard A, Saint-Maurice JP, Bel A, Merland JJ, Houdart E. Coil embolization of an aortic arch false aneurysm. J Endovasc Ther 2002; 9:922– 925. 11. Inoue K, Hosokawa H, Iwase T, et al. Aortic arch reconstruction by transluminally placed endovascular branched stent graft. Circulation 1999; 100 (suppl):316 –321.
CCA ⫽ common carotid artery, SCA ⫽ subclavian artery
DESPITE advances in the surgical management of thoracic aneurysms, the morbidity and mortality rates associated with this operation remain alarmingly high (1,2). The evolution of endoluminal stent-graft repair for abdominal aortic aneurysms lends support to the application of this technique to thoracic aneurysms. Perceived benefits of this less-invasive procedure encompass a reduction in cardiac, pulmonary, renal, and neurologic complications. Specific circumstances that may warrant pursuit of this emerging technology include coexisting severe cardiopulmonary disease, acute dissection, or pseudoaneurysms. We present a case of an anastomotic aortic arch aneurysm repaired with a custom-made stent-graft
From the Division of Vascular Surgery (M.K.E.) and Section of Interventional Radiology (S.A.R.), Northwestern Memorial Hospital, Feinberg School of Medicine, Northwestern University, 201 East Huron Street, Suite 10-105, Chicago, Illinois 60611. Received April 27, 2004; revision requested June 17; revision received and accepted June 19. Address correspondence to M.K.E.; E-mail: [email protected] M.K.E. receives research support from W. L. Gore & Associates, Inc. and Cook, Inc., and serves as a consultant for Medtronic AVE, Guidant, and Cordis. S.A.R. has identified no conflicts of interest. © SIR, 2004 DOI: 10.1097/01.RVI.0000137405.46922.0F
after a left subclavian artery (SCA)–to– common carotid artery (CCA) transposition. Proximal extension for a type I endoleak resulted in coverage of the left common carotid artery managed with a “kissing” bare stent technique.
CASE REPORT A 68-year-old man with a symptomatic penetrating aortic ulcer in the proximal descending thoracic aorta had an open interposition Dacron graft repair 1 year before presentation. His medical history also included a remote aortobifemoral bypass graft. A surveillance computed tomography (CT) scan at 1 year demonstrated large pseudoaneurysms arising from the proximal and distal anastomotic sites (Fig 1) and a native aortic diameter of 30 mm. Angiography confirmed these findings and revealed nonvariant arch anatomy (Fig 2). Endoluminal repair of the pseudoaneurysm with a modular custom-made stent-graft system was recommended. The entire procedure was performed in an operating room angiography suite with a 15-inch image intensifier (Philips Medical Systems, Andover, MA) under general anesthesia. As a result of the short distance (5 mm) between the left SCA and the proximal pseudoaneurysm in the dis-
tal arch (“seal zone”), a standard left SCA/CCA transposition was performed, providing an additional 15 mm of sealing. Next, the right limb of the aortobifemoral graft was surgically exposed via a groin incision for subsequent delivery of the stent-graft system. The components of the modular graft were manufactured with use of 35-mm ⫻ 5-cm Gianturco Z stents (Cook, Bloomington, IN) covered with an ironed woven polyester fabric (Cooley Veri-soft Dacron; Meadox Medicals/Boston Scientific, Oakland, NJ) as originally described by Dake et al (3). The endografts were fashioned in 5-cm and 10-cm length systems and fully covered with Dacron. After the administration of systemic heparin, the right limb of the aortobifemoral graft was accessed and, over a stiff guide wire (Lunderquist wire; Cook), a 22-F ⫻ 60-cm length Teflon delivery sheath (Keller-Timmerman sheath; Cook) was positioned distal to the left CCA. This sheath was used for sequential delivery of the components in a proximal-to-distal orientation. During the time of deployment for each endograft, brief (10 –12 seconds) cardiac arrest was achieved with systemic administration of adenosine (4). After placement of two 10-cm-long components, an aortogram revealed continued filling of the proximal pseudoan-
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“Kissing” Carotid Stent Exclusion of an Anastomotic Arch Aneurysm
November 2004
JVIR
Figure 1. CT scans showing large pseudoaneurysms arising from the proximal and distal anastomotic sites. (a) Large black arrow, innominate artery; small black arrow, left common carotid artery; small white arrow, Dacron graft; large white arrow, proximal pseudoaneurysm. (b) Large black arrow, ascending aorta; white arrow, distal pseudoaneurysm; small black arrow, distal Dacron graft.
eurysm (Fig 3). The proximal type I endoleak was successfully sealed after placement of an additional 5-cm endograft, which also resulted in coverage of the left CCA orifice. This was rescued with retrograde cannulation of the left CCA via the open neck incision, followed by stent implantation of the left CCA orifice with a Genesis 8-mm ⫻ 39-mm stent (Cordis, Miami Lakes, FL) in a “kissing” configuration with the existing Gianturco-based Z stent-graft. The radial force of the Genesis stent was sufficient to displace the Z stent-graft away from the common carotid artery origin. Component overlap sites were “seated” with use of a compliant 27-mm balloon. The completion aortogram revealed total exclusion of the pseudoaneurysms and brisk filling of the left CCA and SCA/CCA transposition through the stent-implanted segment (Fig 4). The patient’s postoperative course was uneventful, and he was discharged home 3 days later and prescribed a regimen of aspirin and clopidogrel. CT at 6-month follow-up revealed complete exclusion of the pseudoaneurysms as well as patency of the left common carotid stent (Fig 5). This report was approved by the institutional review board at our institution.
Figure 2. Angiography confirming CT findings of pseudoaneurysms and revealing nonvariant arch anatomy. (a) Large white arrow, proximal pseudoaneurysm; small white arrow, Dacron repair; large black arrow, distal pseudoaneurysm; small black arrow, native aorta. (b) Large black arrow, distal pseudoaneurysm; small white arrow, neck of pseudoaneurysm; large white arrow, Dacron graft; small black arrow, descending thoracic aneurysm.
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Number 11
Eskandari and Resnick
Figures 3, 4. (3) Aortogram after placement of two 10-cm-length components. Note continued filling of the proximal pseudoaneurysm. The white arrow indicates a subclavian carotid transposition; the black arrow indicates a type I endoleak. (4) Completion aortogram shows total exclusion of the pseudoaneurysms and brisk filling of the left CCA and SCA/CCA transposition through the stent-implanted segment. The black arrow indicates the left common carotid stent; the white arrow indicates the stent-graft.
DISCUSSION Conventional open repair of aortic arch anastomotic aneurysms is fraught with problems (1). The widespread use of endografts for the treatment of abdominal aortic aneurysms has fostered a significant interest in broadening its application to include the proximal aorta. Although an attractive concept, successful endoluminal exclusion of aortic arch aneurysms can be plagued by difficult arch anatomy and requires coverage of one or more of the great vessels to attain a sufficient seal zone for the stent-graft components (5). Published reports for endoluminal management of arch aneurysms are limited and most frequently bundled within an institutional experience of thoracic stentgraft repairs (6,7). For proximal descending or distal arch thoracic aneurysms, intentional coverage of the left SCA without bypass or with extraanatomic bypass of the great vessels to achieve a longer seal-zone has been used. These include left SCA/CCA transposition and right CCA/left CCA bypass. Un-
fortunately, such efforts may be precarious or impossible among patients with an existing left mammary-based coronary bypass or those with vertebral artery disease. When additional seal-zone length is needed up to the innominate artery despite an extraanatomic bypass, one group has used a modified, or “scalloped,” stent-graft (8). Other options include coil embolization and branched stent-graft repair (8 –11). In the case report by Chapot et al (10), 2-year follow-up after coil embolization of a saccular pseudoaneurysm with a small communication between the aortic lumen and the aneurysm showed no increase in sac size. Unfortunately, this intervention has limited application because many anastomotic aneurysms do not have small necks, as exemplified by our case. In addition, absence of flow does not guarantee long-term prevention of continued aneurysm growth as a result of endotension. Stent-graft repair appears to have a theoretic advantage over coiling because of complete exclusion of flow and transmitted pressure into the an-
•
1319
eurysm. The most notable example has been the report by Inoue et al (11). To date, to our knowledge, this is the only report of a successfully deployed unibody branched stent-graft used to treat an aortic arch aneurysm. More recently, Chuter et al (9) have reported results with use of a combination of a modular branched stent-graft after extraanatomic bypass for an arch aneurysm. Each of these reports provides new and innovative ways to deal with elective repair of aneurysms in various locations of the aortic arch. A unique feature of our report is the application of a bailout kissing stent technique for inadvertent coverage of a great vessel. The resultant coverage was primarily a result of the long rigid struts of the stents coupled with the sharp angulation of the aorta at the proximal sealzone site. Perhaps the use of shorter stents (ie, 2.5 mm vs 5.0 mm) would have better accommodated the angulated aorta in this case. The use of this particular salvage technique hopefully will not need to be incorporated into the revolutionized thoracic stentgrafts currently employed in ongoing clinical trials.
CONCLUSION Modular stent-graft repair of thoracic aneurysms is a feasible shortterm solution to the vexing problem of an anastomotic arch pseudoaneurysm. The kissing stent configuration described herein may allow for extended application of this technology in patients with a short proximal stent-graft landing zone. The long-term success compared with traditional open repair remains to be validated through ongoing clinical trails. References 1. Crawford ES, Svensson LG, Coselli JS, Safi HJ, Hess JR. Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch. Factors influencing survival in 717 patients. J Thorac Cardiovasc Surg 1989; 98:659 – 673. 2. Coselli JS, Conklin LD, LeMaire SA. Thoracoabdominal aortic aneurysm repair: Review and update on current strategies. Ann Thorac Surg 2002; 74(suppl):S1881–S1884. 3. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascu-
1320
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“Kissing” Carotid Stent Exclusion of an Anastomotic Arch Aneurysm
Figure 5. CT scan at 6-month follow-up shows complete exclusion of the pseudoaneurysms as well as patency of the left common carotid stent. (a) Large white arrow, left carotid stent; small white arrow, proximal stent graft; black arrow, thrombosed pseudoaneurysm. (b) White arrow, thrombosed pseudoaneurysm; black arrow, distal stent-graft. (c) Threedimensional reconstruction of the left common carotid stent.
November 2004
JVIR
Volume 15
Number 11
lar stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994; 331:1729 –1734. 4. Dorros G, Cohn JM. Adenosine-induced transient cardiac asystole enhances precise deployment of stentgrafts in the thoracic or abdominal aorta. J Endovasc Surg 1996; 3:270 –272. 5. Criado FJ, Clark NS, Barnatan MF. Stent graft repair in the aortic arch and descending thoracic aorta: a 4-year experience. J Vasc Surg 2002; 36:1121–1128. 6. Cambria RP, Brewster DC, Lauterbach SR, et al. Evolving experience with
Eskandari and Resnick
thoracic aortic stent graft repair. J Vasc Surg 2002; 35:1129 –1136. 7. Scharrer-Pamler R, Kotsis T, Kapfer X, Gorich J, Orend KH, Sunder-Plassmann L. Complications after endovascular treatment of thoracic aortic aneurysms. J Endovasc Ther 2003; 10: 711–718. 8. Kruger AJ, Holden AH, Hill AA. Endoluminal repair of a thoracic arch aneurysm using a scallop-edged stentgraft. J Endovasc Ther 2003; 10:936 – 939. 9. Chuter TA, Schneider DB, Reilly LM,
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Lobo EP, Messina LM. Modular branched stent graft for endovascular repair of aortic arch aneurysm and dissection. J Vasc Surg 2003; 38:859 – 863. 10. Chapot R, Aymard A, Saint-Maurice JP, Bel A, Merland JJ, Houdart E. Coil embolization of an aortic arch false aneurysm. J Endovasc Ther 2002; 9:922– 925. 11. Inoue K, Hosokawa H, Iwase T, et al. Aortic arch reconstruction by transluminally placed endovascular branched stent graft. Circulation 1999; 100 (suppl):316 –321.