# 3D printing-assisted triple-vessel in situ fenestration combined with a diameter-restricting technique for a complex giant aortic arch aneurysm in an octogenarian: a case report and technical innovation

## TL;DR

A high-risk elderly patient with a large aortic arch aneurysm was successfully treated using a new endovascular technique involving 3D printing and diameter restriction, avoiding open surgery.

## Contribution

A novel endovascular approach combining 3D printing-assisted fenestration and diameter-restricting stent techniques for complex aortic arch aneurysms in elderly patients.

## Key findings

- 3D printing-assisted ex vivo fenestration allowed precise stent modeling and eliminated blind puncture complications.
- A diameter-restricting technique improved stent apposition and reduced endoleak risk in a challenging anatomical gradient.
- The procedure achieved complete aneurysm exclusion with no neurological complications at 6-month follow-up.

## Abstract

Aortic arch aneurysms involving branch vessels traditionally require open surgery with cardiopulmonary bypass, which poses prohibitive risks for octogenarians with complex comorbidities. This case demonstrates the successful application of total endovascular aortic repair (TEVAR) with three dimensional (3D) printing-assisted triple-vessel in situ fenestration and a diameter-restricting technique in an 85-year-old patient with a giant (9.0 cm) aortic arch aneurysm involving the left subclavian artery.

The involvement of the three arch branches (brachiocephalic trunk, left common carotid artery, and left subclavian artery) necessitated precise revascularization. In comparison with traditional in situ fenestration, 3D printing-guided ex vivo fenestration enabled pre-release stent modeling on a 1:1 aortic arch replica (error <1 mm), allowing anatomically tailored fenestration positioning and eliminating blind puncture-related complications. A proximal stent diameter-restricting technique addressed the challenging anchoring zone gradient (33.6 → 27.3 mm), improving stent apposition and reducing type I endoleak risk. Intraoperative multiaccess reconstruction (femoral/axillary/cervical approach) achieved complete aneurysm exclusion. Postoperative computed tomography angiography on day 4 confirmed patent branches and absence of endoleaks, while 6-month follow-up demonstrated stable stent position and no neurological complications.

This case highlights that TEVAR with 3D printing-assisted ex vivo fenestration and a diameter-restricting technique can serve as a viable alternative to open surgery for high-risk octogenarians with complex aortic arch aneurysms, overcoming traditional limitations of in situ fenestration while preserving cerebral perfusion. Further studies are warranted to validate this approach in larger populations.