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A 79-year-old male patient with a history of a myocardial infarction, atrial flutter, and a reduced ejection fraction of 30-35 % was treated in 2010 for a juxtarenal aneurysm of 56 mm. Because of a compromised cardiac function, an EVAR with a chimney graft (Ch-EVAR) for the left renal artery (LRA) was preferred over open surgery. Fenestrated and branched technology was not available at that time. A Gore Excluder (RLT311417) was used as aortic endoprosthesis in an aortic neck of 24 mm in combination with a Viabahn (Gore, 7 9 50 mm) in the LRA as a chimney graft (CG). A sealing zone of 19-20 mm was created. The procedure was uncomplicated, although the postoperative CT scan showed a small type 1a endoleak through the gutter formed by the Viabahn. Because of the magnitude and the stable aneurysmal diameter, a watchful waiting policy was adopted. Five years after the initial repair, enlargement of the aneurysmal sac till 7.2 cm was detected. A CT scan showed an extension of the aneurysmal disease with dilatation of the neck and a clearly increased gutter. A custom-made endoprosthesis (X-tra design, Jotec Hechingen) with 4 branches was designed according to the anatomy of the patient with a branch for the celiac trunk (CT), the superior mesenteric artery (SMA), the right renal artery (RRA), and the CG (Fig. 1). The branch for the CG was placed at 15°instead of 0°to avoid interference with the branches of the SMA and the RRA, originating also at 0°and 330°within a close range. Preoperatively, a spinal catheter was inserted in order to prevent spinal ischemia. Access was obtained through the left axillary artery and both common femoral arteries. The endoprosthesis was introduced through the left groin and advanced to the right level. After deployment, the branches were sequentially catheterized from the axillary access using a 7-Fr sheath in combination with a preshaped catheter. The cannulation was started with the SMA to avoid accidental covering by the branch coming from the chimney graft. E-Ventus (Jotec, Hechingen) covered stents were used as bridging stentgrafts. Completion angiography showed a complete resolution of the endoleak with a good position of the branches without kinking. Because of severe calcification and bleeding at the distal external iliac artery, a short iliofemoral bypass was needed at the end of the procedure.

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