Three new techniques for creation of a steerable sheath, a 4F snare, and bidirectional sheath inversion using existing endovascular materials

Use of target vessel ballooning to facilitate endovascular treatment in the case of branched endovascular aneurysm repair with a retrograde approach

A case of a new technique for branched endovascular aneurysm repair with a retrograde approach and ostial stenosis of the target vessel is reported. An angioplasty balloon was placed within the target vessel and used to give added stability to catheter advancement to place the stiff guidewire needed for placement of a bridging stent graft. In brief, a standard guidewire was first placed inside the target vessel through the retrograde approach. Next, the balloon was placed from outside the stent graft, again through a contralateral retrograde approach. Then, the angioplasty balloon was inflated, and a support catheter was advanced to the balloon and then slowly deflated to allow the catheter to advance. Finally, the stiff guidewire was placed. Subsequently, the bridging stent was placed and deployed. This technique is feasible and can be used in selected cases to use a retrograde approach when ostial stenosis of the target vessel is present.

Technical note: An alternative use of a steerable homemade for the treatment of chronic total occlusion of an iliac artery

INTRODUCTION

The complexity of the peripheral recanalization comes from the difficulty to cross the lesion or get into the subintimal space and its re-entry afterward, with a high risk of complications like artery dissection and/or rupture, which are life-threatening complications. To our knowledge, we report the first case of the use of a homemade steerable sheath for the successful revascularization of a heavy chronic total occlusion in a patient with unsuitable upper vascular access.

TECHNIQUE

By contralateral vascular access and the use of a 6Fr 55-cm Cook Flexor sheath and a pre-looped 0.014" choice guidewire, a steerable homemade sheath was used to achieve the support, pushability, and steer needed to access the subintimal space at the origin of a heavy occluded common iliac artery, thus giving us the ability to cross the lesion.

CONCLUSIONS

The homemade steerable sheath is feasible, quick, cheap, and easy to use, sparing the use of re-entry systems and catheters for the attempts of subintimal navigation. In addition, this technique gives the advantage to steer the catheters and wires as needed, avoiding non-desired re-entry points with secondary collaterals lumen compromise or extensive dissections.

Complete Transfemoral Endovascular Repair with Homemade Steerable Sheath of Intercostal Artery Patch Aneurysm after Open Repair of Thoracoabdominal Aortic Aneurysm

The aim of this paper is to describe a case of complete transfemoral approach for endovascular treatment of a large intercostal patch aneurysm with custom-made stent-graft in a patient with Loeys-Dietz syndrome and previous multiple aortic operations. Three aortic components were used to exclude a 65-mm intercostal patch aneurysm. Because of the reimplantation site of supra-aortic trunks in a previous open arch repair, we used a complete transfemoral approach with a homemade steerable sheath to deliver all the renovisceral bridging stents through the downward side-branches. No major complications were registered. A 6-month follow-up resulted uneventfully, and an initial shrinkage of the aneurysmal lesion was found. The use of a homemade steerable sheath was safe and effective for catheterization and stenting of all the target vessels through the downward side branches.

Physician-modified Steerable Endovascular Catheter

We demonstrate a simple, intraoperative modification to a 65 cm Beacon Tip Kumpe catheter (Cook Medical) using readily-available components in order to increase its functionality during endovascular procedures. The steerable endovascular catheter has near-spherical range, improving accessibility to challenging anatomy over conventional catheters as demonstrated by our qualitative modeling. In addition, the modification provides structural reinforcement at the catheter tip leading to precise wire advancement. Use of the steerable catheter was demonstrated in vivo during contralateral gate cannulation of an endovascular aneurysm repair, however it holds broad applications in visceral, branched and fenestrated cannulations. Physician-modified devices offer the potential to improve endovascular techniques and reduce additional procedure costs while avoiding regulatory board approval required of novel steerable endovascular devices.

The Early Outcomes of BeGraft Peripheral Plus in Branched Endovascular Repair of Thoracoabdominal Aneurysms

OBJECTIVE

No bridging stent-graft (BSG) has been specifically designed for branched endovascular aortic repair (BEVAR) and therefore different "off-label" stent-grafts have been used. Recently, a third generation of balloon-expandable stent-graft has become available. Here we evaluate the outcomes of the BeGraft Peripheral Plus (B+) used as a BSG for internal/externalor inner branches during BEVAR.

MATERIALS AND METHODS

Consecutive patients undergoing BEVAR using B+ as a BSG since its release in 2017 were included into the study. The primary endpoints were technical success and target vessel patency during follow-up. Secondary endpoints included the need for adjunct extension and relining of the BSG, branch instability rate, including occlusion, reinterventions for restonosis, kink, fracture, or endoleak (types 1 and 3).

RESULTS

A total of 163 visceral branches in 46 patients were included with a median follow-up 15 months (4-36 months). Primary technical success was achieved in all visceral branches (69 inner branches and 94 internal/external branches) with the exception of 1 BSG that required serial dilatation until full expansion was achieved with overall branch patency was 98% at 2 years. An additional stent-graft was necessary in 35 branches (21%) following deployment of a B+ BSG to cover a longer bridging distance and optimize the distal and proximal sealing. Relining of B+ BSG was not routinely carried out during the index procedure and a self-expanding uncovered nitinol stent was necessary in only 3% of branches to smooth the distal transition zone between the BSG and target vessel. There were 4 events (2.4%) of branch related instability, including 2 occlusions and 2 late reinterventions for a partial in-stent-graft thrombosis.

CONCLUSION

Our study findings show satisfactory early outcomes of B+ as a BSG in BEVAR with low occlusion and reintervention rates. Extensions of BSG might be required to achieve adequate seal in the target vessels but routine relining BSG in branches was not required.

WILD Sheath Technique: "WIre Loop Directional" Sheath for Retrograde Femoral Access in Branched Endovascular Aortic Aneurysm Repair

Branched endovascular aortic aneurysm repair (BEVAR) necessitates upper limb access (ULA) to facilitate the antegrade cannulation of downward directional branches and the placement of the bridging stent grafts. Various technical solutions to avoid ULA have been proposed and successfully applied in a limited number of cases. This can be necessary in specific clinical scenarios such as hostile aortic arch and descending thoracic aortic anatomy, or in the case of previous aortic arch and supra-aortic vessels surgery complicating the conventional approach with ULA in BEVAR. Taking inspiration from the prior description of a precursory technique, we report the application of our technique in BEVAR procedures, using standard introducer sheaths as a directional stable platform to facilitate an "All Femoral Access" (AFA) approach without the need for ULA, snaring or commercial steerable sheaths. Our concept is based on utilizing a wire loop to form a directional sheath (WILD sheath technique).

Early outcomes of Jotec inner-branched endografts in complex endovascular aortic aneurysm repair

OBJECTIVE

Complex aortic endografts have evolved to include inner branches to overcome specific challenges with existing technologies. We have reported the early outcomes of endovascular aortic aneurysm repair (EVAR) using a Jotec inner branched endograft (iBEVAR).

METHODS

All patients who had undergone complex EVARs using extra-design engineering iBEVAR (Jotec GmbH, Hechingen, Germany) from 2018 to 2020 at a single center were reviewed. The patient demographics, cardiovascular risk factors, anatomic features of the aneurysms, and target vessels were recorded. The reasons for using inner branches instead of fenestrated and standard branched endografts and the procedural details, outcomes, and reintervention during follow-up were examined.

RESULTS

A total of 110 patients were treated with branched and fenestrated endografts during the study period, of whom 18 patients had had a patient-specific custom-made iBEVAR endograft with downward inner branches. The technical success rate was 100%. A total of 68 target vessels were cannulated, and bridging stent-grafts were placed successfully in all. The reasons for choosing the iBEVAR design included unfavorable target vessel trajectory for fenestrated repair (n = 15), excessive infrarenal aortic angulation and/or adverse iliac access vessels for fenestrated repair (n = 11), the presence of a narrow aortic lumen (n = 14), and/or to reduce aortic coverage compared with that with standard outer branched repair (n = 14). We also used iBEVAR to treat type Ia endoleaks after failed EVAR with a short main body (n = 5). The median contrast volume used was 120 mL (range, 48-200 mL), with a median fluoroscopy screening time of 66 minutes (range, 35-136 minutes) and a median dose-area product of 17,832 dGy∙cm² (range, 8260-55,070 dGycm²). No 30-day mortality and no major complications occurred. One early intervention was required for a suspected type Ib endoleak from an iliac limb and one late intervention for in-stent stenosis in a renal bridging stent-graft. One patient had died of non-aortic-related causes at 3 months. All other patients continued with follow-up with their aneurysms excluded, patent target vessels, and no type I or III endoleak identified at a median follow-up of 12 months (range, 1-26 months).

CONCLUSIONS

The use of Jotec extra-design engineering endografts incorporating downward inner branches resulted in satisfactory early outcomes with a low reintervention rate. The technology has the potential to be a useful addition to our armamentarium for treating complex aortic endografts; however, long-term outcomes data are needed.

Stabilization of a steerable sheath during retrograde access to antegrade-oriented branches in complex endovascular aortic aneurysm repair

During branched endovascular aneurysm repair, cannulation of the visceral target vessels through antegrade branches and insertion of bridging stents are frequently done from an upper extremity access. A retrograde femoral approach is a challenging alternative when an antegrade approach is not preferred. Herein, we describe a technique to increase stability of a steerable sheath, using a single suture, for bridging antegrade-facing branches from a retrograde access. This technique secures the sheath's deflected tip and provides more pushability to the steerable sheath.

Use of steerable catheters for endovascular procedures: Report of a CASE and literature review

We report a case of a celiac trunk stenting using a steerable guiding catheter, to fix a residual endoleak following fenestrated endovascular repair (FEVAR) of a thoraco-abdominal aortic aneurysm (TAAA). A systematic search of the literature about the use of steerable catheters was also performed on Pubmed according to the PRISMA Guidelines, including all papers in which the device was used for in vivo endovascular procedures. In our case report, the patient had undergone a failed attempt of cannulation due to the presence of a severely angulated and stenosed ostium of the vessel. A steerable catheter was then used to fix the residual endoleak. The search of the Literature retrieved 544 papers. Of them, 13 met the inclusion criteria and were therefore assessed. The use of steerable sheaths and catheters was reported as effective and safe for the cannulation of 157 target vessels in 131 endovascular procedures, with a success rate of 95.5% and no complications. The use of a steerable guiding catheter in our experience was safe and effective for the selective cannulation of a severely stenosed and angulated celiac trunk, to correct a residual endoleak after FEVAR for TAAA. Steerable catheters could be useful tools for the selective cannulation of target vessels with a challenging ostium.