One-Stage Endovascular Treatment of a Symptomatic Penetrating Ulcer in the Lusorian Artery and an AAA: A Challenging Case in a Rare Entity.

Introduction: We report a case of a 57-year-old man with a successful total endovascular treatment of a symptomatic penetrating arterial ulcer (PAU) of a lusorian artery (LA) together with a standard endovascular abdominal aortic aneurysm (AAA) repair. The LA is an aberrant subclavian artery and a congenital aortic arch anomaly with a reported prevalence of 0.4-2.6%. Typical for the base of the LA is a Kommerell diverticulum making an endovascular approach even more difficult.
Methods: The patient was admitted to our hospital due to an unspecific retrosternal and hypopharyngeal pulsation feeling. The contrast computed tomography scan revealed a PAU in the middle of the aberrant right subclavian artery, apart from the size progression of an asymptomatic and followed-up AAA. Beside a standard abdominal endovascular aortic repair (EVAR), a total endovascular PAU exclusion was achieved using an Endurant tapered leg extension. The system was released in a back-table procedure and then remounted reversed on the system which now could be introduced via a transverse arteriotomy of the right axillary artery.
Results: The technical result was excellent, no endoleak was observed, and the symptoms disappeared immediately. The patient was discharged symptom free after 5 days.
Summary: This is so far the first reported total endovascular therapy of a symptomatic PAU of an LA. There are no tapered leg extensions or main bodies with a necessary working length for a femoral approach and correct sizing at the same time available on the market. The technical success was, therefore, based on the possibility of releasing and remounting parts of the Endurant Stent Graft System in emergency cases in a back-table setting. Although this is off-label use in experienced hands, it is easy to handle and can surely help the endovascular surgeon in some challenging situation where no standard stent-graft system is available.
(Copyright © 2017 Elsevier Inc. All rights reserved.)