Complicated Zone 0 TEVAR and Revision of Frozen Elephant Trunk

Young Marfan patient with previous aortic reconstructions including aortic root replacement with mechanical valve Bentall, Type II thoracoabdominal aortic repair, re-do elephant trunk, and TEVAR of elephant trunk to previous descending graft. He developed a Type IA endoleak and increase in size aortic arch aneurysm. Previous TEVAR migrated distally out of the elephant trunk. We proceeded with an endovascular repair however, passage of wires into the previous Bentall graft was challenging. After exhausting all options in a retrograde fashion we access the right radial artery and placed a buddy wire into the ascending graft and entered the TEVAR in a retrograde fashion. This wire was snared in the descending graft and then with an angled glide from below we were able to flip the catheter into the ascending graft. Great care was taken to avoid the mechanical valve with our wires and catheters. The TEVAR was deployed just distal to the takeoff of the trifurcated graft to the head vessel. Two TEVAR components were delivered with the last piece anchored in to the descending graft.