Fenestrated and branched endovascular devices have expanded the treatment options for complex aortic pathology, and physician-modified endografts (PMEGs) have emerged as a potential alternative for urgent repair. However, an important unresolved question is whether renal artery preservation should always be pursued during emergent repair. We report two cases of ruptured thoracoabdominal aneurysms treated with PMEGs at Hospital Geral Roberto Santos between January and February 2026. Based on computed tomography angiography, fenestrations were created using electrocautery and reinforced with a snare catheter loop, whereas directional branches were constructed using self-expanding covered stents. Both patients presented with ruptured Crawford type IV aneurysms and retroperitoneal hematomas. In the first case, a 26-year-old man underwent PMEG repair with preservation of the celiac trunk and superior mesenteric and right renal arteries, while the left renal artery was intentionally sacrificed. In the second case, a 68-year-old woman underwent repair with directional branches to the superior mesenteric artery and celiac trunk, without preservation of the renal arteries. Technical success was achieved in both cases; however, clinical outcomes differed substantially. Emergency repair of ruptured thoracoabdominal aneurysms using PMEGs is a feasible strategy when custom devices are unavailable. Although renal artery preservation remains an important objective, these two cases illustrate that intentional renal artery sacrifice may occasionally be unavoidable in critically unstable patients with unfavorable renal anatomy.
Castleman disease (CD) represents an uncommon lymphoproliferative condition that can manifest as a mediastinal mass and resemble other thoracic pathologies. Establishing a definitive diagnosis before surgery is often difficult, making histopathological analysis crucial. We present the case of a 38-year-old man in whom a posterior mediastinal lesion was incidentally identified and initially interpreted as a neurogenic tumor on imaging. The mass was successfully removed via video-assisted thoracoscopic surgery (VATS). Subsequent pathological evaluation revealed hyaline-vascular unicentric CD. This case underscores the need to consider CD in the differential diagnosis of posterior mediastinal masses and further supports the role of VATS as a safe and effective minimally invasive approach.
