Present and Future of Branched Stent Grafts in Thoraco-abdominal Aortic Aneurysm Repair: A Single-centre Experience

Endovascular management of thoracic aortic aneurysms

The overall survival of patients with thoracic aortic aneurysm (TAA) has improved significantly in the past few years. Endovascular treatment, proposed as an alternative to surgery, has been considered a therapeutic innovation because of its low degree of invasiveness, which allows the treatment of even high-surgical risk patients with limited complications and mortality. A major limitation is the lack of adequate evidence regarding long-term benefit and durability because follow-up has been limited to just a few years even in the largest series. The combination of endovascular exclusion with visceral branch revascularization for the treatment of thoraco-abdominal aortic aneurysms involving the visceral aorta has also been attempted. As an alternative, endografts with branches represent a technological evolution that allows treatment of complex anatomy. Even if only small numbers of patients and short follow-up are available, this technical approach, which has with limited mortality (<10%) and paraplegia rates, to expand endovascular treatment to TAA seems feasible. With improved capability to recognize proper anatomy and select clinical candidates, the choice of endovascular stent-graft placement may offer a strategy to optimize management and improve prognosis.

Endovascular treatment for a thoracic-abdominal aortic aneurysm without fenestrations or branches

We describe a case of a patient with a thoraco-abdominal aortic aneurysm, affecting the origin of the celiac trunk, with the particularity of the normal aortic diameter in the segment between superior mesenteric artery and both renal arteries. Endovascular treatment was performed with no fenestrated or branch endoprosthesis. The procedure was divided into two steps. In the first attempt, an aortic prosthesis was deployed at the infrarenal aorta. Then, a thoracic endoprosthesis was deployed in a second procedure. In this case, the celiac trunk was intentionally occluded in order to increase the distal landing zone. At the end, the segment between the superior mesenteric artery above and below the renal arteries was covered by the uncovered struts of both endoprosthesis, with no effects in visceral artery flow. Multislice computed tomographic angiography after six months revealed complete patency of the superior mesenteric artery, both renal arteries and good back-filling of the branches of the celiac axis, with no evidence of aortic endoleak.

Technique of Adding a Diameter-reducing Wire to the Modified TX2 Fenestrated Stent Graft

One of the technical limitations of surgeon-modified fenestrated stent grafts is the lack of a diameter-reducing wire, which facilitates catheterization of target branches if there are errors of device design, alignment, or implantation. This article describes a technique of adding a diameter-reducing wire to the modified TX2 fenestrated stent graft for compassionate use in aortic emergencies or high-risk patients who do not have access to manufactured devices. The modified Cook TX2 stent graft was created using reinforced fenestrations with gold nitinol markers. After the TX2 stent was fully unsheathed, one of the nitinol wires located in the inner cannula was withdrawn and redirected externally through and through the fabric of the stent graft. Each Z stent was constrained using the nitinol wire for support and two nonlocking polypropylene loops. The use of a diameter-reducing wire facilitates side branch catheterization by allowing longitudinal and rotational movement to the modified fenestrated stent graft in patients where there is misalignment between the fenestration and the origin of the target vessel.

Endovascular therapy for thoracic aneurysm diseases: PRO

Although the long-term durability of stent grafts is still a concern, stent-graft treatment is already the best option in a large number of patients with descending thoracic aortic diseases who are poor candidates for surgical repair, or in an acute setting. With improved capability to recognize proper anatomy and select clinical candidates, the choice of endovascular stent-graft placement may offer a strategy to optimize management and improve prognosis.