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巻頭言

Nakase, A

Inoue, Y

市病・心臓血管外科

Posted at the Institutional Resources for Unique Collection and Academic Archives at Tokyo Dental College,
Available from http://ir.tdc.ac.jp/
Title A rare case of lethal Najuta endograft collapse
Author(s) Nakase, A; Inoue, Y
Journal Journal of cardiothoracic surgery, 18: 306
URL http://hdl.handle.net/10130/6427
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Description
Nakase and Inoue  
Journal of Cardiothoracic Surgery          (2023) 18:306  
https://doi.org/10.1186/s13019-023-02436-6
CASE REPORT
A rare case of lethal Najuta endograft 
collapse
Akihiro Nakase1† and Yoshito Inoue1*† 
Abstract 
Background The development of fenestrated endograft, Najuta endograft Kawasumi Laboratories, Inc, Tokyo, Japan) 
in thoracic endovascular aortic repair (TEVAR) has enabled the treatment of aortic arch aneurysms approaching zone 
0 without the need of supra-aortic vessel branch reconstruction. However, the indications of Najuta remain controver-
sial due to complications such as endograft collapse, which is rare and lethal.
Case presentation We here report a 75-year-old male patient with arch saccular aneurysm. Because of his liver 
cirrhosis, 2 debranching TEVAR has chosen as a treatment using Najuta. After extrathoracic bypass was performed, 
a CTAG stent graft was implanted distal to the LSCA in order to deliver Najuta stent graft steadily. Najuta stent graft 
was successfully positioned in zone 0. However, he was suffered from stent-graft collapse. After additional TEVAR 
to salvage stent-graft collapse to zone 0, he complicated type A dissection, which was treated by ascending aorta 
replacement. After salvage operation complicated multiorgan failure and he died.
Keywords Endograft collapse, Najuta, TEVAR, Thoracic aortic aneurysm
Background
Najuta endograft is one of the fenestrated endografts 
that enables treatment of aortic aneurysm with zone 0–1 
landing.
However, there are fatal complications, including endo-
graft collapse [1, 2]. A careful planning of the procedure 
is mandatory to avoid complications such as endograft 
collapse that has been reported in rare cases of aortic 
trauma and dissection [1]. We report a rare case of fatal 
Najuta endograft collapse.
Case presentation
A 75-year-old man who had a distal arch saccular aneu-
rysm (60  mm) underwent operation. Because of liver 
cirrhosis (Child Pugh B), endovascular treatment was 
chosen. Computed tomography (CT) showed a 60-mm 
arch aneurysm (Fig.  1A). The diameter of the Aneu-
rysm, proximal neck, and distal neck diameters were 
60 mm, 36 mm, 30.7 mm, respectively. Aortic arch angle 
was 77 degrees. 2-debranch TEVAR using a fenestrated 
endograft (Najuta) was performed to achieve long proxi-
mal sealing length and preserve brachiocephalic artery. 
First, Right subclavian artery to left carotid and left 
subclavian artery bypass using T-shaped graft (Propat-
ene, Gore), was performed prior to stent graft insertion 
(Fig. 1B). Given the aneurysm length of 60-mm, a CTAG 
stent graft of 31-mm diameter × 15-mm length (W.L. 
Gore and Associates Flagstaff, AZ, USA) was implanted 
just distal to the LSCA to supply Najuta steadily. The 
fenestration of the Najuta of 42-mm diameter was suc-
cessfully positioned in zone 0 and delivered to the brachi-
ocephalic artery (Fig. 2A). Molding of the endograft after 
Open Access
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which 
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the 
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or 
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line 
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory 
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this 
licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecom-
mons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Journal of
Cardiothoracic Surgery
†Akihiro Nakase and Yoshito Inoue contributed equally.
*Correspondence:
Yoshito Inoue
yinoue@tdc.ac.jp
1 Department of Cardiovascular Surgery, Tokyo Dental College Ichikawa 
General Hospital, Sugano 5-11-13, Ichikawa, Chiba 272-8513, Japan
Page 2 of 3Nakase and Inoue  Journal of Cardiothoracic Surgery          (2023) 18:306 
deployment of Najuta stent graft was not performed in 
order to avoid aortic dissection. It was an off-label use as 
the proximal neck length was 16.9 mm (< 20 mm).
Six hours postoperatively, he experienced acute hypo-
tension, pancytopenia, and worsening lactic acidosis, 
resulting in systemic circulation failure. Emergent CT 
showed proximal collapse of the endograft and type I a 
endoleak with systemic blood flow obstruction (Fig. 2B). 
Due to the patient’s poor general condition, a minimally 
invasive treatment was chosen. An additional stent graft 
34-34-150 (Valiant Captiva, Medtronic, Dublin, Ireland) 
was placed, with molding, just distal of the the second 
fenestration emergently at the ascending aorta to bail out 
Najuta collapse (Fig. 2C). Brachiocephalic artery flow was 
maintained. Consequently, the endoleak reduced, and 
systemic circulation improved. Nevertheless, hepatic fail-
ure continued due to hemolysis and progressive anemia 
the following day. Emergent open chest salvage was per-
formed on the third postoperative day. Because the stent 
graft was in the ascending aorta, we established a cardio-
pulmonary bypass with femoral arterial inflow and right 
atrial outflow. A fresh retrograde type A aortic dissec-
tion and collapse of the proximal part of the Najuta were 
observed during surgery. The entry was located at the 
lesser curvature of the ascending aorta between proximal 
Najuta stent graft and Variant. Aortic dissection occurred 
Fig. 1 A Acute aortic arch angulation and a distal arch aneurysm involving the left subclavian artery are also shown on the preoperative computed 
tomography scan. B Using 8 mm heparin-bonded expanded polytetrafluoroethylene grafts, an extra thoracic bypass from the right subclavian 
artery to the left subclavian artery and to the left common carotid artery was accomplished
Fig. 2 A Final angiography revealed preservation of the brachiocephalic artery and debranching bypass flow and demonstrated full exclusion 
of the aneurysm. B Computed tomography shows proximal collapse of the endograft (arrow heads). C At additional TEVAR, angiogram showed 
a type I an endoleak and proximal collapse of the stent graft
Page 3 of 3Nakase and Inoue  Journal of Cardiothoracic Surgery          (2023) 18:306  
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after 2nd stent graft insertion to ascending aorta by bal-
loon dilatation of the endograft. Following the successful 
closure of the false lumen caused by the removal of the 
proximal 2 stent by suturing the stent graft to the aorta, 
the patient’s hemodynamics were stabilized (Video 1). 
However, he had an extensive cerebral infarction with 
brain edema. Therefore, extracranial decompression sur-
gery was required, resulting in temporary improvement 
of symptoms. The patient had complicated repeat exten-
sive cerebral infarction. On the 19th postoperative day, 
the patient died of multiorgan failure.
Discussion
Najuta stnet-graft is a semicustom system created to fit 
the morphology of the patient’s aortic arch requiring arch 
vessel fenestration. However, as it consists of an inner 
skeleton, it may not be able to track the acute angulation 
of the lesser curvature owing to relatively weak radial 
force.
Stent-graft collapse itself is a rare complication and 
there are only 5 reported cases of Najuta endograft col-
lapse as far as we investigated [2, 3]. Various factors are 
related to such occurrence. Acute aortic arch angle is 
one of the factors of stent-graft collapse. Most cases of 
type Ia endoleak after TEVAR with the precurved fenes-
trated endograft occur because the endograft is subjected 
to haemodynamic action, making it sink into the aortic 
aneurysm owing to the small radial force, even with ade-
quate proximal landing in zone 0 [2].
Canaud et  al. examined 29 cases of stent-graft col-
lapse, of which the total death rate was 6.8% [1]. Most 
collapses have occurred in young patients treated for 
traumatic aortic trauma or dissection but not in patients 
with atherosclerotic aneurysms because of the steep arch 
angulation in traumatic patients [4, 5]. To prevent poor 
apposition of the proximal edge of the stent graft in sit-
uations with severe aortic arch angulation, a stent graft 
with a more effective proximal anchorage system and a 
stronger radial force is required.
Conclusions
We experienced a Najuta stent-graft collapse after 
TEVAR for aortic arch aneurysm. To prevent endograft 
collapse, the indication for TEVAR in patients with highly 
angulated aortic arches might be carefully considered.
Funding
Not applicable.
Availability of data and materials
The data that support the findings of this study are available from the cor-
responding author, [Yoshito Inoue], upon reasonable request.
Declarations
Ethics approval and consent to participate
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Received: 28 February 2023   Accepted: 4 November 2023
References
 1. Canaud L, Alric P, Desgranges P, Marzelle J, Marty-Ané C, Becquemin JP. 
Factors favoring stent-graft collapse after thoracic endovascular aortic 
repair. J Thorac Cardiovasc Surg. 2010;139:1153–7.
 2. Furuta A, Azuma T, Yokoi Y, Domoto S, Niinami H. The midterm results of 
thoracic endovascular aortic repair with a precurved fenestrated endo-
graft in zone 0–1. Eur J Cardiothorac Surg. 2020;58:722–9.
 3. Nakayama T, Nakamura Y, Yasumoto Y, Yoshiyama D, Kuroda M, Nishijima 
S, et al. Collapse of Najuta endograft (aortic arch graft) in patient with 
intermittent paraparesis. Indian J Thorac Cardiovasc Surg. 2022;38:521–4.
 4. Muhs BE, Balm R, White GH, Verhagen HJ. Anatomic factors associated 
with acute endograft collapse after Gore TAG treatment of thoracic aortic 
dissection or traumatic rupture. J Vasc Surg. 2007;45:655–61.
 5. Cao L, Ge Y, He Y, Wang X, Rong D, Lu W, et al. Association between aortic 
arch angulation and bird-beak configuration after thoracic aortic stent 
graft repair after type B aortic dissection. Interact Cardiovasc Thorac Surg. 
2020;31:688–96.
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