Advanced Technical Considerations for Implanting the t-Branch Off-the-Shelf Multibranched Stent-Graft to Treat Thoracoabdominal Aneurysms.

PURPOSE: To demonstrate different techniques and device modifications that can expand the anatomic suitability of the off-the-shelf multibranched t-Branch for treatment of thoracoabdominal aortic aneurysm. TECHNIQUE: The t-Branch device is not customized for specific patient anatomy, and the most frequent limitations to its use are an inadequate sealing zone and renal artery anatomy. Experience with this device has prompted the development of several techniques that can be employed to maximize the suitability of this stent-graft. Advice is offered on modification of the device to minimize the risk of paraplegia or better match patient anatomy. Maneuvers are explained to ease delivery through tortuous anatomy or existing stent-grafts, catheterize visceral target vessels, select a bridging stent, reduce ischemia time in the limbs, and alter the configuration of the branches. CONCLUSION: Employing adjunctive maneuvers can increase the anatomic suitability of the t-Branch; in our experience, these techniques have increased the applicability to more than 80% of all elective and urgent thoracoabdominal aortic aneurysm cases.

Sorghum silage supplemented with crambe meal improves dry matter intake and milk production in crossbred Holstein cows.

We studied the feed intake and milk production of Holstein × Zebu crossbred cows fed sorghum silage diets and concentrates, with and without the addition of crambe meal. Using a change-over design for a total of 120 days, eight cows were fed two diets (concentrates + silages with and without crambe meal) in four 30-day periods, with four replications (animals). The crambe meal diet increased (P < 0.05) the dry matter intake (DMI), crude protein intake (CPI), and non-fibrous carbohydrates intake (NFCI) as well as milk production (4.3%). No difference was noted (P > 0.05) for the milk composition between the treatments. Crambe meal as an additive in sorghum silage (100 g/kg in natural matter) showed a great potential for introduction in dairy farming as it substantially increases CP intake, does not reduce food intake, raises animal productivity, and does not affect milk composition.

"Snare-Ride": A Bailout Technique to Catheterize Target Vessels With Unfriendly Anatomy in Branched Endovascular Aortic Repair.

PURPOSE: To describe a novel endovascular bailout technique for successful completion of target vessel stenting during branched stent-graft repair of thoracoabdominal aortic aneurysms (TAAA) after encountering difficulties with standard catheterization techniques. TECHNIQUE: Technical difficulties when using fenestrated and branched grafts should be expected, especially in difficult anatomy or when an off-the-shelf device (eg, standard 4-branch device) is used that does not perfectly "match" the anatomy. The "snare-ride technique" facilitates antegrade transaxillary side branch catheterization and stent placement during TAAA branched grafting using a snare via a transfemoral approach. The branch of the graft is catheterized from an axillary access. The respective target vessel is then catheterized via a femoral access. An Indy snare is advanced over the transfemoral wire and positioned near the entrance of the target vessel. The transaxillary wire inside the branch of the graft is then advanced, snared, and pushed inside the target vessel with the snare. The procedure is thereafter continued with antegrade bridging of the target vessel in routine fashion. CONCLUSION: The snare-ride technique can be a useful maneuver to catheterize target vessels with difficult anatomy in TAAA branched stent-graft repair. Early experience shows safety and feasibility.