Total endovascular repair of a post-TEVAR Crawford extent II thoracoabdominal aortic aneurysm with concomitant renal artery aneurysm: a case report.

Emergency management of post-dissection thoracoabdominal aortic aneurysm (pd-TAAA) in patients with complex anatomy, multiple comorbidities, and severely compromised physiological reserve presents a formidable challenge. Achieving accurate and safe endovascular rescue is extremely difficult, particularly in resource-limited environments where custom-made devices are not available. A 56-year-old male was admitted emergently with a giant Crawford extent II pd-TAAA measuring 71 mm in maximum diameter, complicated by a concomitant left renal artery aneurysm and reduced physiological reserve, including renal and hepatic insufficiency. Due to urgent symptoms and unavailability of off-the-shelf branched stent grafts, total endovascular repair was performed using a 3D-printed model-guided physician-modified stent graft system (PMSGS). This technique utilizes in vitro replication of the patient's anatomy to achieve accurate alignment between stent fenestrations and visceral artery ostia. Intraoperatively, a stent-assisted coil embolization strategy was applied to exclude the renal artery aneurysm, achieving "zero warm ischemia" protection for the kidney. Concurrently, a multimodal neuroprotective strategy, including the use of an iliac branch endoprosthesis and cerebrospinal fluid drainage, was utilized. Postoperative imaging confirmed complete aneurysm exclusion, patent visceral branches, and absence of spinal cord ischemia or renal function deterioration. This case elucidates that for pd-TAAA patients with complex anatomy and multiple high-risk factors in emergency settings, the 3D-printed model-guided PMSGS technique provides an accurate and effective alternative treatment strategy. Integration of this technique with comprehensive perioperative management efficiently solves anatomical matching difficulties and maximizes organ protection in the absence of custom-made devices.