A Novel Cautery Instrument for On-Site Fenestration of Aortic Stent-Grafts: A Feasibility Study of 18 Patients

Stephen, Edwin; Joseph, George; Sen, Indrani; Chacko, Sujith Thomas; Premkumar, Prabhu; Varghese, Lalee; Selvaraj, Dheepak

doi:10.1583/13-4304mr.1

Cited by 19 publications

(13 citation statements)

References 23 publications

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“…A single fenestration for the LSA of appropriate size and location is made in between the endograft stent struts, in line with the radiopaque figure-8 mid-marker, using a thermal cautery instrument. 4 Thereafter, a radiopaque nitinol wire is sewn onto the edge of the fenestration ( Figure 1A ).…”

Section: Techniquementioning

confidence: 99%

“…Endovascular repair is an effective way of treating aortic arch pathology, 1 and fenestrations in the endografts can help preserve flow into supra-aortic branches destined to be covered by the device. 2 – 5 Precise deployment of these fenestrated arch endografts is important to correctly orient the fenestrations toward the branches for which they are intended. The fenestrations must then be cannulated if covered stents are to be deployed through them into the side branches to achieve a seal at each location.…”

Section: Introductionmentioning

confidence: 99%

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Externalized Guidewires to Facilitate Fenestrated Endograft Deployment in the Aortic Arch

et al. 2015

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Purpose: To describe a precannulated fenestrated endograft system utilizing externalized guidewires to facilitate aortic arch endovascular repair and to report its use in 2 patients with challenging anatomy. Technique: For distal arch repair, a fenestration for the left subclavian artery (LSA) is made onsite in a standard thoracic endograft tailored to the patient anatomy; it is precannulated with a nitinol guidewire (NGw), which is passed from the femoral artery and externalized from the left brachial artery prior to endograft delivery system introduction over a parallel stiff guidewire. Steps are then taken to remove guidewire intertwining, prevent NGw wrapping around the delivery system, and orient the LSA fenestration superiorly when the delivery system moves into the arch. Gentle traction on the ends of the NGw during endograft deployment facilitates proper fenestration alignment. A covered stent is deployed in the LSA fenestration. The technique is illustrated in a patient with congenital coarctation of the aorta and descending aortic aneurysm. For total arch repair, endograft fenestrations are made for all 3 arch branches; the left common carotid artery (LCCA) and LSA fenestrations are each cannulated with NGws, which travel together from the femoral artery, pass through a LSA snare loop, and are exteriorized from the LCCA. After endograft deployment, the innominate artery fenestration is separately cannulated using right brachial access. Placement of a parallel externalized hydrophilic guidewire passing through the LCCA fenestration (but not the LSA snare loop) and removal of the LCCA fenestration NGw allows exteriorization of the LSA fenestration NGw from the left brachial artery by pulling the LSA snare. Covered stents are deployed in all 3 fenestrations. The technique is presented in a patient with type B aortic dissection. Conclusion: Use of the precannulated fenestrated endograft system described is feasible and has the potential to make aortic arch endovascular repair simpler, more reliable, and safer.

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Section: Techniquementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Externalized Guidewires to Facilitate Fenestrated Endograft Deployment in the Aortic Arch

et al. 2015

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“…Three circular fenestrations were made [10-mm diameter for the IA and 8-mm for the LCCA and left subclavian artery (LSA)], and their edges were strengthened with 0.014-inch radiopaque wire sutured on with 5-0 polypropylene. 10 Two radiopaque figure-8 markers were fixed onto the endograft in the 12 o'clock position and brought up to the surface (in contact with the endograft sheath) during resheathing of the endograft ( Figure 6B and C). Orienting these markers toward the outer curvature of the aortic arch during introduction of the endograft delivery system facilitated correct rotational orientation of the fenestrations, which were not prewired, 11 as the arch was not distorted and direct cannulation of the fenestrations seemed feasible.…”

Section: Endograft Preparationmentioning

confidence: 99%

Cerebral Protection Using Percutaneous Normothermic Bilateral Antegrade Cerebral Perfusion During Total Arch TEVAR in a Patient With Shaggy Aorta

et al. 2020

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Purpose: To report a technique of global cerebral embolic protection (CEP) designed for use during thoracic endovascular aortic repair (TEVAR). Technique: Arterial cannulas are inserted percutaneously in the right axillary artery (12-F) and left common carotid artery (LCCA; 10-F) to provide normothermic antegrade cerebral perfusion during TEVAR with neuromonitoring. Inferior vena cava blood is drawn using a 19-F femoral cannula, filtered, oxygenated, and delivered through independent roller pumps to the arterial cannulas. Static CEP is obtained by balloon occlusion of the 3 aortic arch branches proximally, resulting in complete separation of aortic and cerebral blood flow; static CEP is used during aortic endograft delivery and deployment. Dynamic CEP, obtained by creating flow reversal in the innominate artery and proximal LCCA, is used at all other times. Successful use of this CEP technique is illustrated in a patient with shaggy aorta undergoing fenestrated total arch TEVAR. Conclusion: Percutaneous normothermic bilateral antegrade cerebral perfusion provides effective CEP during TEVAR.

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“…The use of fenestrations in the thoracic arch has also become an adjunct for surgeons to place covered stent‐grafts into the subclavian artery in order to extend the proximal landing zone while preserving flow to the left vertebral artery and spinal cord . A thermal cautery instrument was employed to create fenestrations in thoracic stent‐grants that were strengthened using a nitinol wire . There also exist customized thoracic arch fenestrated endografts proposed by Cook for the complete exclusion of all vessels of the arch although these are currently still considered experimental .…”

mentioning

confidence: 99%

“…Based upon previous results of a clinical series , it now seems appropriate to continue to pursue a design for a device that will allow for in situ fenestration of an “off the shelf” endograft . Most of the research to date has focused on the feasibility of the technique . However, the issue of durability has been raised .…”

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confidence: 99%

In Vitro Laser Fenestration of Aortic Stent‐Grafts: A Qualitative Analysis Under Scanning Electron Microscope

et al. 2016

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In situ fenestration of stent-grafts allows patients with life threatening aortic pathologies to be amenable to emergent "off the shelf indications for use" percutaneous treatments as a bail out technique. Three types of aortic stent-grafts were subjected to laser fenestration in a physiological saline solution followed by balloon angioplasty using 8, 10 or 12 mm in diameter noncompliant balloons. The morphology and the size of fenestrations were observed under optical and scanning electron microscopy. The damage to the fabrics was analyzed and quantified. The creation of fenestrations was feasible in all devices, with varying degrees of fraying and/or tearing. The monofilament twill weave (Medtronic Valiant) tore in two directions (warp and weft) while the multifilament weave fenestrations showed more fraying (Anaconda Vascutek and Zenith TX2 Cook). The size and directions of tearing were more predictable with the 8 mm diameter balloon whereas the results obtained with the 10 and 12 mm diameter balloons were more unpredictable. The fenestrations were free of melting of the yarns and blackening of the filaments. The in situ fenestration is feasible but the observed damage to the fabric constructions must be carefully considered. This procedure must currently be limited to urgent and emergent life threatening cases because it is off indications for use for approved devices.

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A Novel Cautery Instrument for On-Site Fenestration of Aortic Stent-Grafts: A Feasibility Study of 18 Patients

Abstract: This simple-to-use instrument makes on-site creation of aortic stent-graft fenestrations easy, accurate, and precise. The instrument is inexpensive, robust, and easily sterilized.

Cited by 19 publications

References 23 publications

Externalized Guidewires to Facilitate Fenestrated Endograft Deployment in the Aortic Arch

Externalized Guidewires to Facilitate Fenestrated Endograft Deployment in the Aortic Arch

Cerebral Protection Using Percutaneous Normothermic Bilateral Antegrade Cerebral Perfusion During Total Arch TEVAR in a Patient With Shaggy Aorta

In Vitro Laser Fenestration of Aortic Stent‐Grafts: A Qualitative Analysis Under Scanning Electron Microscope

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