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

Use of Physician-Modified Fenestrated Stent-Graft With Wire Loop Technique for Complex Aortic Arch Aneurysm

BACKGROUND

To present a novel means of overcoming a deviation when treating an aortic arch aneurysm with a physician-modified fenestrated stent-graft.

METHODS

A 78-year-old man showed a rapidly expanding aortic arch aneurysm, and the limited landing zone required the use of a fenestrated/branched arch endograft. Physician-modified fenestrated stent-grafts are considered suitable for patients in an acute setting. The device became malrotated in a clockwise direction during deployment; therefore, cannulation of the first inner branch using a through-and-through wire technique was needed. The final angiogram showed a good result.

CONCLUSION

Thoracic endovascular repair of an aortic arch aneurysm using a through-and-through technique can be considered for high-risk patients in an acute setting.

Use of a Steerable Sheath for Antegrade Catheterization of a Supra-aortic Branch of an Inner-Branched Arch Endograft via a Percutaneous Femoral Access

Purpose: To describe the use of a steerable sheath from a femoral access for antegrade catheterization of the left common carotid artery (LCCA) in an inner-branched arch endograft. Technique: This technique is demonstrated in a patient with residual aortic dissection after replacement of the ascending aorta for acute type A aortic dissection. He presented 4 years later with aneurysmal degeneration of the thoracoabdominal aorta and a proximal tear located in the aortic arch. A 2-stage hybrid approach was devised to treat the patient. An axilloaxillary crossover graft (left to right) with plug occlusion of the innominate artery was performed initially. Later, a dual-branched custom-made device was implanted. To avoid an additional LCCA cutdown for retrograde branch access, an 18-F steerable sheath was used through a percutaneous femoral access. Two wires were delivered within the steerable sheath: the first one was directed into the left subclavian artery to stabilize the sheath position in the ascending aorta; the second wire was used to catheterize the first inner branch and the LCCA to deploy the covered bridging stent. Conclusion: Transfemoral access to catheterize antegrade branches for supra-aortic vessels is feasible using a large steerable sheath in branched endovascular arch repair.