Management of Late TEVAR Migration Using a Novel Branched Endograft: First Western Experience

Background: Late distal migration after thoracic endovascular aortic repair may lead to type Ia endoleak and represents a challenging long-term complication, particularly in patients previously treated with complex aortic reconstructions. Case Summary: A 76-year-old woman with a history of endovascular repair of a type II thoracoabdominal aortic aneurysm underwent surveillance imaging that revealed 50-mm distal migration of the proximal thoracic endovascular aortic repair with a type Ia endoleak in the setting of aortic tortuosity. Proximal relining with preservation of the left subclavian artery was performed using the new Cratos stent graft. The delivery system enabled accurate branch alignment and secure proximal sealing. Completion angiography and 1-month computed tomography angiography confirmed correct positioning, branch patency, and absence of endoleaks. Discussion: This is the first reported Western implantation of the Cratos and the first use in aneurysmal disease. The case highlights technical advantages over the Castor system, particularly in tortuous anatomy. Take-Home Messages: Cratos may expand fully endovascular options for complex proximal thoracic relining; broader experience is needed to confirm durability.