Fig. 4

A 69-year-old male presented with an extensive thoracic aortic aneurysm, a right aortic arch, and an isolated left subclavian artery (SCA). Initially, we performed an elephant trunk ascending aorta replacement and reconstructed the cervical branches. Subsequently, we planned for thoracic endovascular aortic repair (TEVAR) to address the aortic arch and descending aortic aneurysm. a contrast-enhanced computed tomography revealed a dilated third intercostal artery measuring 4 mm (arrowhead) and a coarse mural thrombus within the aneurysm (star). Embolization of the artery was planned to prevent a type 2 endoleak; b a three-dimensional volume-rendering image demonstrated that the highly tortuous third intercostal artery (arrow) anastomosed with the left costocervical trunk, which arises from the left SCA, and that the left vertebral artery (VA) branched off closely to the left costocervical trunk. Considering the risk of peripheral embolization of the VA due to a substantial mural thrombus, we punctured the left brachial artery and accessed this artery from the left SCA; c a 1.6-Fr microcatheter (Carnelian Marvel S; Tokai Medical Products, Aichi, Japan) was advanced near the origin of the third intercostal artery, and we attempted to place a 0.014-inch coil (Target XL soft coil; Stryker, Fremont, CA, USA) measuring 5 mm in diameter and 10 cm in length. However, the pathway’s tortuosity was so severe that we could not implant the entire coil, and half of it remained within the catheter (dotted line); d therefore, the coil was intentionally detached within the catheter and flushed with saline solution for placement; e seven additional 0.014-inch coils (six target XL soft coils and one Azur soft 3D coil; Terumo, Tokyo, Japan) were tightly placed using the intentional early detachment technique; f final angiogram after TEVAR shows successful aortic repair without any endoleaks