The Ascending Aorta as an Exit Site for a Through-and-Through Wire in TEVAR

Sheath-Anchoring for Rail Guidewire Technique to Advance and Deploy Thoracic Endograft in Hostile Anatomy

BACKGROUND

To describe a bailout technique to advance and precisely deploy thoracic endograft in the ascending aorta in case of difficulty crossing the aortic arch.

CASE REPORTS

A 73-year-old man presented with a large ruptured aneurysms in the descending aorta. During the TEVAR, stent-graft passage through the aortic arch was impossible due to the severe tortuosity of the aorta. The problem has been resolved using the sheath-anchoring rail guidewire (SARG) technique.

RESULTS

Through an axillary access, a snare was used to capture the stiff wire from the femoral access. A sheath was advanced over the stiff wire to the ascending aorta and placed there. By exploiting the grip of the sheath on the stiff in the ascending aorta, it was possible to handle the tension, move the delivery system through the arch and carefully deploy the graft.

CONCLUSION

The SARG is a simple and quick learning technique which can be useful for Physicians dealing with complex aortic arch anatomy.

Externalized transapical guidewire technique after artificial aortic valve replacement during complete endovascular aortic arch repair

An externalized transapical guidewire (ETAG) technique has been used for safe delivery of high-profile devices through a tortuous aorta to zone 0, which is currently precluded after mechanical artificial aortic valve replacement (AVR). The aim of the study was to report one center's experience (based on 3 cases) of a unique modification to the ETAG technique used for the first time during total endovascular aortic arch repair after AVR. This report contains technical notes regarding a new method of steering the guidewire from the apex inside the artificial aortic valve during total endovascular aortic arch repair after AVR and the details crucial in preparation for this mini-invasive procedure. As a conclusion, the ETAG technique could be performed after mechanical AVR with active positioning of the guidewire carried out under the control of transesophageal echocardiography.

Single-center mid-term experience with chimney-graft technique for the preservation of flow to the supra-aortic branches

Objectives

To investigate the feasibility and the mid-term outcomes of the chimney-graft technique for the revascularization of supra-aortic branches in patients with thoracic aortic pathologies involving the aortic arch.

Methods

A retrospective analysis of a prospectively maintained database between January 2010 and July 2016 was performed. Primary endpoints were 30-day and overall mortality. Secondary endpoints were technical success, target vessel patency, stroke/transitory ischemic attack and type I/III endoleak rate.

Results

A total of 30 patients (80% male, median age 70.0 years) were treated using the chimney-graft technique for the supra-aortic branches. The indication was a degenerative aneurysm in nine patients (32%) and a type B Stanford aortic dissection and a penetrating aortic ulcer in the descending aorta in seven patients (23%), respectively. In six patients (20.0%), the indication was an type Ia endoleak after previous endovascular thoracic repair, whereas a pseudoaneurysm after previous open repair of the descending aorta was the indication in one patient (3%). Twenty-three patients (77%) were treated electively, five (17%) emergently and two (7%) urgently because of free rupture. Technical success was achieved in 90% of patients. The 30-day/in-hospital mortality was 17% (5/30). A retrograde dissection was presented in five patients. Four patients experienced a cerebrovascular event. Eight patients had type Ia endoleak and 10 had type II. During the median follow-up of 16 months (range: 0–56), four further patients died: one in respiratory insufficiency, one due to a ruptured abdominal aortic aneurysm, one in meningitis and the last one for unknown reason. The chimney-graft patency was 100%. According to the Kaplan–Meier curve, the estimated survival at one year was 66 ± 9%.

Conclusions

The chimney-graft technique, despite a technically demanding strategy, is a useful tool as bailout procedure in our armamentarium for high-risk patients, unsuitable for open or hybrid repair.

Antegrade thoracic endovascular aortic repair using an ascending aortofemoral through-and-through wire technique for a severely tortuous aorta associated with rickets

Background

Severe aortic tortuosity of the access route often prevents successful complete exclusion of an aneurysm in thoracic endovascular aortic repair (TEVAR).

Case presentation

We performed antegrade TEVAR on a 79-year-old man with right hemiparesis. We deployed the stent graft from the ascending aorta with a tube graft conduit to treat a descending thoracic aortic aneurysm associated with rickets and multiple comorbidities. Although the application of a ministernotomy diminished the potential advantages of endovascular treatment in view of less invasive surgery, antegrade TEVAR using an ascending aortofemoral through-and-through wire technique was a good option in this patient because a conventional retrograde approach was not feasible due to his severely tortuous aorta.

Conclusions

To avoid device-related complications, it is crucial to make a prudent preoperative decision on a patient-by-patient basis, taking into account the appropriate access site, adjuvant guidewire technique, and adjunctive surgical interventions.