Multi-Branched Thoracoabdominal Endovascular Aortic Repair With Branch Access Through a Left Thoracotomy and Descending Thoracic Aortic Conduit: A Novel and Effective Alternative Access.

PURPOSE: To demonstrate an alternative access to perform directional branch catheterization during complex endovascular aortic repair. TECHNIQUE: Urgent endovascular aortic repair was indicated to treat a symptomatic post dissection thoracoabdominal aneurysm with large infrarenal dilatation with an off-the-shelf t-Branch endograft (Cook Medical, Bloomington, IN, USA). Traditional proximal arterial accesses were not suitable due to a previous aortic arch endograft. A novel approach was performed through a left postero-lateral thoracotomy, isolation of the descending thoracic aorta and anastomosed a polyester graft conduit to allow sheaths passage to the thoracoabdominal aorta with subsequently directional branch catheterization. CONCLUSION: The descending thoracic aortic conduit technique is an effective alternative for directional branch catheterization and should be considered whenever traditional proximal arterial accesses are not suitable and other endografts configurations not considered due to anatomic limitations.

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.

"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.

Thoracoabdominal aortic aneurysm: a totally endovascular approach with a branched stent-graft.

This video depicts a step-by-step description of a totally endovascular approach to treat a patient with thoracoabdominal aneurysm, using a branched stent-graft system. We compare the pre and post-operative computerized tomography and show 3D illustrations and real-life images of the technique.

Uso de endoprótesis fenestrada para la reparación de aneurismas aórticos complejos: reporte de dos casos / Fenestrated endografts for the treatment of complex aortic aneurysms: report of two cases

In the last decade endovascular repair of infrarenal aortic aneurysms (EVAR) has become increasingly popular. However, until recently patients with juxtarenal abdominal aortic aneurysms (JAAA) or with thoracoabdominal aortic aneurysms (TAA) were not candidates for EVAR due to the lack of an adequate landing zone to deploy the endograft. Because of considerable morbidity and mortality that traditional open surgery of these aneurysms entail, new endografts with fenestrations and branches have been developed to treat these patients. We present our initial experience with two cases, both male with coronary artery disease considered high-risk for traditional open repair. The first patient has a 4.1 cm sacular JAAA; it is repaired with a fenestrated endograft with branches for both renal arteries (RA), superior mesenteric artery (SMA) and a scallop for the celiac trunk (CT). The second patient has a 5.9 cm TAA with a previous aorto bifemoral bypass; because the CT is chronically occluded it is repaired with a fenestrated endograft with branches for both RA and SMA. In both patients post operative course was uneventful. Follow-up at 11 months and 30 days respectively, show adequate exclusion of the aneurysm with patency of all revascularized vessels. This new therapeutic procedure allows treatment of high-risk patients with complex aortic aneurysms in whom conventional repair entails a prohibitive surgical risk.

La reparación endovascular de un aneurisma aórtico abdominal infrarrenal (EVAR) se ha popularizado en la última década. Sin embargo, hasta ahora los pacientes con aneurisma aórtico abdominal yuxtarrenal (AAAY) o aneurisma aórtico tóracoabdominal (AATA) no eran candidatos a EVAR por ausencia de una zona sana donde apoyar la endoprótesis tubular. La reparación convencional se asocia a una morbimortalidad considerable, por lo que se han desarrollado endoprótesis capaces de acomodar ramas de la aorta que permiten tratar estos aneurismas en forma mínimamente invasiva. Presentamos la experiencia inicial de dos casos, ambos de sexo masculino y portadores de enfermedad coronaria considerados de alto riesgo para cirugía abierta. El primero, portador de un AAAY sacular de 4,1 cm de diámetro; se repara mediante el uso de endoprótesis fenestrada con ramas a ambas arterias renales (AR), arteria mesentérica superior (AMS) y una escotadura para el tronco celíaco (TC). El otro, portador de AATA de 5,9 cm de diámetro, un puente aorto bifemoral previo y TC crónicamente ocluido; se repara con endoprótesis fenestrada con ramas para las AR y AMS. Ambos pacientes presentaron una evolución post operatoria favorable. El seguimiento a 11 meses para el primero y 30 días para el segundo demuestra exclusión del aneurisma y permeabilidad de todas las arterias revasculari-zadas. Este nuevo procedimiento terapéutico abre la posibilidad de tratar pacientes de alto riesgo, portadores de aneurismas aórticos complejos, para los que una alternativa convencional implica un alto riesgo quirúrgico.