April 2026

CARDIOVASCULAR

CASE REPORT: COMPLEX AORTIC RECONSTRUCTION USING DOUBLE-BARREL FROZEN ELEPHANT TRUNKS

Featuring: Christopher K. Mehta, MD
Clinical Scenario
A 60‑year‑old patient with obesity and chronic obstructive pulmonary disease presented with a chronic type B aortic dissection of unknown chronicity and significant aneurysmal degeneration of the aortic arch and descending thoracic aorta.
Pre-operative imaging revealed a particularly complex anatomy, including:
  • A 4.1 cm proximal entry tear in zone 3
  • Aneurysmal degeneration to 6.5 cm in the distal arch
  • A very small true lumen with an extensively calcified dissection septum
  • Visceral arteries arising from both true and false lumens

​Four‑dimensional flow MRI confirmed minimal septal fenestrations, indicating that exclusion of the false lumen would compromise visceral perfusion. Given the patient’s comorbid conditions, open thoracoabdominal repair posed prohibitive risk, while standard endovascular techniques were limited by poor proximal landing zones and unfavorable septal characteristics.
 
Procedural Strategy
To address these competing anatomic and physiologic constraints, our team pursued a custom hybrid approach:
  • Total aortic arch replacement via sternotomy
  • Parallel (“double‑barrel”) frozen elephant trunk stent graft deployment into both the true and false lumens
  • Immediate extension thoracic endovascular aortic repair (TEVAR) into both lumens during the same operation

This approach allowed treatment of the aneurysmal arch while preserving flow through both lumens to maintain renal and visceral perfusion, an essential requirement in this patient.
 
Key Technical Highlights
  • Antegrade deployment of two stent grafts, one into each lumen, under direct visualization
  • Creation of a reinforced circumferential sewing ring by tacking both grafts together and to the native septum
  • Elimination of potential gutter leaks between grafts
  • Retrograde TEVAR extension from femoral access to achieve distal sealing in both lumens

​Intraoperative cone‑beam CT confirmed complete exclusion of the pseudoaneurysm with preserved branch vessel patency.
 
Outcome
The patient experienced an uneventful post-operative course and was discharged home on post-operative day 6. Follow‑up CTA demonstrated:
  • Successful exclusion of the arch aneurysm
  • Maintained perfusion through both true and false lumens
  • Patency of all visceral and renal branches

​At two‑year follow‑up, imaging confirmed continued device stability with no endoleak, no further aneurysmal degeneration, and no need for reintervention.
 
Practice Implications
  • Appropriate for select patients requiring arch intervention with preservation of dual‑lumen perfusion
  • Avoids limitations of electrosurgical septotomy in patients with narrow, calcified septa
  • Provides a durable platform for potential future distal aortic interventions, if needed
Christopher K. Mehta, MD, Assistant Professor of Cardiac Surgery

​Dr. Mehta was one of the lead authors of this study.

Refer a Patient

Northwestern Medicine welcomes the opportunity to collaborate with you in caring for your patients. ​

You May Also Like