Technical Solutions for Common Problems in TEVAR:

Abstract

Thoracic endovascular aortic repair (TEVAR) is rapidly emerging as an important treatment option for several indications, and it would not be unreasonable to predict that endograft treatment may well become the predominant form of therapy for many, if not the majority, of patients. However, several unresolved issues remain, and the need for further improvements and technological refinements will not cease any time soon. Ranking high among these issues are the challenges related to endovascular access and aortic branch management, which constitute the main focus of this review. Achieving safe and successful endovascular access for introduction and deployment of the stent-graft device is a crucially important and often challenging step during TEVAR, but arterial injury has been, and continues to be, an all-too-common occurrence to this day. A clear understanding of the relevant issues and available technical solutions can go a long way toward preventing such catastrophes. A preponderance of thoracic aortic pathologies tend to develop adjacent to or within the branched segments. It is therefore not surprising that branch management issues have risen to the top of the entire TEVAR field. Debranching and vessel relocation techniques have added a whole new dimension to the therapy because they can expand or create suitable landing zones proximally and distally, thereby broadening the applicability of endograft technologies to a much larger number of patients.

Transcatheter aortic valve implantation when classical access routes are unavailable

“…We felt that access via the LCC artery after surgical exposure by an experienced vascular surgeon would be safe and easy to perform in our patient, whose right carotid artery and circle of Willis were fully patent. Furthermore, the distal common carotid artery is commonly used in vascular surgery for retrograde supra-aortic trunk stenting, known as Criado's technique [5], a rapid (5-10 min) and simple procedure that can be performed under local anesthesia and is less invasive than a mini-thoracotomy. The left subclavian artery approach can be considerably longer procedure when the artery is located deep in the thorax, and local anesthesia is ineffective due to the vicinity of the brachial nerves.…”

Unfavorable iliac artery anatomy causing access limitations during endovascular abdominal aortic aneurysm repair: application of the endoconduit technique

“…More recently, Peterson and Matsumura 3 proposed the innovative technique of using an "endoconduit", placing a covered stent to act as protection for the iliac arteries during forced dilation and also to facilitate access for the device to deliver the main body of the endoprosthesis, as described in this article. [1][2][3]12 There is little international experience documented in articles and applications have predominantly been as adjuvant to thoracic endovascular aortic repair (TEVAR), 13 with few description of use for abdominal pathologies. 2,14 It is worth noting that we did not find any Brazilian reports, whether for EVAR or for TEVAR.…”

“…Other relevant questions raised include the possibility of hemorrhagic complications caused by reflux from the internal iliac artery, in view of the controlled rupture of the iliac artery, 12,14 but this is apparently no more than a theoretical concern since there are no descriptions of any complications of this type whatsoever during use of the technique. [2][3][4]11,13,14 We consider that ensuring that the covered stent is released and sealed to the common iliac, that the ostium of the internal iliac is covered and that vigorous dilation only occurs in the middle of the covered section, are technical principles that it is of fundamental importance to observe in order to minimize the risk of bleeding from internal iliac reflux. Damage to the artery at the implant site can also occur and it may be necessary to reconstruct damaged segments, which is generally accomplished by interposition of a prosthetic graft between the end of the endoconduit and the common femoral artery, 4 as was done in this case.…”

Partial debranching hybrid stent graft for distal aortic arch aneurysms

“…This approach requires a sternotomy and achieves superior durability to extrathoracic revascularization, but does not have any advantage in terms of less invasiveness. Criado et al [18] proposed a chimney-covered stent placed in the LCCA to preserve the patency of the vessel without surgical revascularization. With retrograde percutaneous puncture of the LCCA, this technique avoids surgical debranching of the LCCA.…”