An Unusual Case of Delayed Complete Aortic Graft Occlusion Treated by Kissing Balloon Expandable Covered Stents and Renal Chimney

Introduction: Late occlusion of the entire stent graft after endovascular aortic repair (EVAR) is a rare condition which often requires open surgery. This is a case of endovascular rescue of chronic total occlusion of an aortic stent graft in a patient at high risk of open surgery and lysis. Report: An 82 year old male was admitted with bilateral lower limb rest pain eight years after EVAR. Endovascular relining with a covered stent under local anaesthesia was planned. Antegrade recanalisation from brachial access was achieved, then VBX balloon expandable covered stents (W. L. Gore & Associates Inc. Flagstaff, AZ, USA) were deployed in a kissing configuration to reline the occluded stent graft, alongside a double renal chimney. The post-operative period was uneventful, and a six month CT angiogram confirmed the technical success with complete patency of the aorto-iliac segment and visceral arteries. Discussion: Complete stent graft thrombosis after EVAR is typically managed by open conversion to aortobifemoral or axillobifemoral bypass graft, surgical thrombectomy or catheter directed thrombolysis, carrying a considerable mortality and morbidity rate. Endovascular relining with kissing covered balloon expandable stents with double renal chimneys is a less invasive option. By offering a unique combination of radial strength and flexibility, associated with a trackable delivery system and a high retention capability, the GORE VBX is the present authors’ preferred stent option for this procedure. The present case shows how endovascular recanalisation by antegrade and retrograde approaches may be an effective option, especially in a patient at high risk of open surgery and lysis.