2007 Abstracts: Mal-Deployment of the Thoracic Endograft

Background: The TAG device is a commercially available endograft for treatment of descending thoracic aortic aneurysms (dTAA). It has a one-step (Sim-Pull) deployment mechanism similar to the Excluder. This report describes 2 cases of failed deployment of the TAG device and the salvage techniques used to complete the procedure.
Case 1: The patient was a 79-yo woman who had 7.5 cm proximal dTAA. She underwent a sequential carotid-carotid-subclavian bypass to gain additional proximal landing zone, followed by a TAG repair. A 31 x 100 mm device was inserted through a 24 Fr sheath and the deployment cord pulled. The proximal end of the device failed to deploy. An 0.018" guidewire was introduced through the space between the device and the delivery catheter and the constraining ePTFE string forcibly broken with angioplasty balloons. The procedure was completed but she sustained a massive stroke and eventually expired on postoperative day 68.
Case 2: A 69-yo man had a 6.1-cm Type III TAAA and underwent a hybrid procedure involving celiac-SMA revascularization (stage I) followed by a TAG stent graft (stage II) repair 9 days later. A 37 x 200 mm device was introduced through a 24 Fr sheath. The deployment cord was pulled but the device failed to deploy at its proximal end (Figure) An 0.014" guidewire was used to cross through the constrained section. Serial angioplasties up to a 12-mm balloon inflated to 8 atm were required to break the ePTFE suture. Interestingly, a second 37 x 200, which was used to extend the repair distally, again failed to deploy in a similar manner and the same maneuvers had to be repeated. The procedure was completed satisfactorily and he was discharged on postoperative day 3. At 8 months, the aneurysm remains stable with no endoleak.
Conclusion: This is an extremely unusual type of device failure that has never been reported in the literature. The mechanism is likely related to the particular stitching technique used for the constraining sleeve of the TAG device. Endovascular specialists using this device should be aware of salvage techniques to avoid the need for surgical conversion.