A 62-year-old man with a history of hypertension, smoking, chronic obstructive pulmonary disease and coronary artery disease had a saccular aneurysm in the distal aortic arch (Figure 1A) involving the origin of the left subclavian artery (LSA), with a maximum diameter of 65 mm and a short proximal neck distancing 13 mm from the origin of the left common carotid artery (LCCA).

Figure 1.

Pre-procedure computed tomography angiography (CTA) showing a large aneurysm in the distal aortic arch involving the origin of the left subclavian artery (A). Follow-up CTA at one month revealed no endoleak and patency of the innominate and LCCA stent grafts (B, C, D).

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He was considered at high surgical risk and was referred for thoracic endovascular aortic repair with simultaneous preservation of perfusion of the innominate artery and LCCA through double-chimney technique.

The procedure was performed under general anesthesia. A Gore® TAG® stent graft was first inserted through the right common femoral artery and deployed at the distal end of the aneurysm, and a second one was inserted into the ascending aorta distally overlapping with the first. Two Gore® VIABAHN® stent grafts were introduced through the right axillary artery and LCCA and deployed at the proximal edge of the proximal TAG stent graft. Post-procedure computed tomography angiography (CTA) revealed a type II endoleak from the LSA, but follow-up CTA at one month revealed no endoleak and patency of the stent grafts (Figure 1B, C and D).

The double chimney is a recently introduced endovascular technique that provides an alternative to surgical treatment of aortic arch disease with preservation of the arch branches. There are a few case reports worldwide with acceptable short-term results, most associated with lower mortality and stroke rates compared to surgical or hybrid techniques. This case represents the first experience in Portugal with the double-chimney technique and long-term data are awaited.