Bail-out technique to detach a locked Viabahn endoprosthesis in branched thoracic endovascular aortic repair.

A 69-year-old female patient presented with a 5.8 cm thoracoabdominal aortic aneurysm Crawford type II after partial arch replacement. She was treated by a branched thoracic endovascular aortic repair procedure using a branched arch endograft with one retrograde branch to the left subclavian artery. After deployment of a Viabahn as a bridging covered stent to the left subclavian artery, the deployment line did not detach and the delivery catheter could not be removed. With the use of a physician-modified sidehole catheter and balloon fixation, the pulling line could be released without displacement of the Viabahn endoprosthesis.

Iatrogenic coarctation caused by branched thoracic endovascular aortic repair treated with Palmaz XL stent and triple kissing balloon technique.

We have described a technique to treat iatrogenic coarctation caused by a branched thoracic endovascular aortic repair (TEVAR) procedure with a Palmaz XL stent (Palmaz Genesis; Cordis Corp, a Cardinal Health Company, Milpitas, Calif) and triple kissing balloons. A 42-year-old woman with Marfan syndrome had presented with aneurysmatic dilatation of the aortic arch 10 years after open aortic arch repair. After successful branched TEVAR, a significant coarctation just short of the left common carotid artery was noted with significant pressure gradient between the ascending and descending aorta. Branched TEVAR in previous open aortic arch replacement can result in iatrogenic coarctation that can be successfully treated using a Palmaz XL stent and triple kissing balloons.

Complex Endovascular Aortic Repair With a Branched Endograft to Revascularize 5 Renovisceral Vessels and an Intercostal Artery in a Marfan Patient.

Purpose: To report a case of thoracoabdominal aortic aneurysm (TAAA) repair treated with a multibranched stent-graft including a prophylactic branch for a large intercostal artery in a Marfan patient at risk for spinal cord ischemia (SCI). Case Report: A 43-year-old man with Marfan syndrome presented with a type IV thoracoabdominal aortic aneurysm (TAAA) and history of multiple previous cardiac and aortic operations over the past 28 years. The maximum diameter of the aneurysm was 60 mm. The patient had 2 right renal arteries and 2 reimplanted segmental arteries (1 occluded). With the goal of preserving both right renal arteries and the large intercostal artery, a 6-branch, custom-made stent-graft was planned and manufactured. Bilateral femoral and right brachial artery access was used. The intercostal artery was catheterized and connected to the retrograde branch from a femoral access. Final angiography and predischarge computed tomography angiography (CTA) showed unimpeded flow to all 6 target vessels. The patient was discharged on postoperative day 10 without clinical signs of SCI. Six-month follow-up CTA demonstrated exclusion of the TAAA and patency of all 6 branches. Conclusion: Multibranched endovascular aortic repair with a branch to a large intercostal artery was technically feasible and clinically successful.

Emergent Use of a Branched Arch Device to Treat an Ascending Aortic Rupture: A Branch-to-Branch Through-and-Through Wire Technique to Compensate for Rotation Error.

Purpose: To present a novel means of overcoming a rotation error when treating a ruptured ascending aorta with a branched arch endograft. Technique: The technique is demonstrated in an 83-year-old patient with cardiac and respiratory comorbidities and a contained rupture of the ascending aorta who was referred for endovascular therapy. Computed tomography angiography (CTA) showed progressive pseudoaneurysm and mediastinal hematoma, but the limited landing zone required the use of an inner branched arch endograft that was designed for another patient. The device became malrotated clockwise during deployment, so cannulation of the first inner branch was done using a branch-to-branch through-and-through wire from the second inner branch. The final angiogram showed a good result, with patency of the supra-aortic vessels and exclusion of the rupture. The patient was discharged 2 weeks later without complications. The 1-month CTA was free from endoleak. The patient returned to his normal activity 3 months later. Conclusion: The use of a branched arch stent-graft for emergent repair of a ruptured ascending aorta is feasible.