Technique of Implantation and Bail-Out Maneuvers for Endovascular Fenestrated Repair of Juxtarenal Aortic Aneurysms

Oderich, Gustavo S.; Mendes, Bernardo C.; Kanamori, Karina S.

doi:10.1177/1531003513512372

Cited by 18 publications

(10 citation statements)

References 14 publications

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“…This technique involves the gradual insertion of the stent-graft under fluoroscopic guidance, with the surgeon making rotational adjustments to maintain the correct orientation of the position markers. 23 This torque applied by the surgeon is in the direction opposite to the measured iliac torsion. However, if the operator inserts the device fully, notes the alignment of the fenestrations, and fully removes the device before adjusting the alignment (multiple insertion technique), the amount of rotation observed in the idealized models was substantially lower.…”

Section: Discussionmentioning

confidence: 99%

Impact of Insertion Technique and Iliac Artery Anatomy on Fenestrated Endovascular Aneurysm Repair

et al. 2019

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Purpose: To develop a mechanically realistic aortoiliac model to evaluate anatomic variables associated with stent-graft rotation and to assess common deployment techniques that may contribute to rotation. Materials and Methods: Idealized aortoiliac geometries were constructed either through direct 3-dimensional (3D) printing (rigid) or through casting with polyvinyl alcohol using 3D-printed molds (flexible). Flexible model bending rigidity was controlled by altering wall thickness. Three flexible patient-specific models were also created based on the preoperative computed tomography angiograms. Zenith infrarenal and fenestrated devices were used in this study. The models were pressurized to 100 mm Hg with normal saline. Deployments were performed under fluoroscopy at 37°C. Rotation was calculated by tracking the change in position of gold markers affixed to the devices. Results: In the rigid idealized models, stent-graft rotation increased with increasing torsion; torsion levels of 1.6, 2.6, and 3.6 mm−1 had mean rotations of 5.2°±0.03°, 11.2°±4.8°, and 27.6°±13.0°, respectively (p<0.001). In the flexible models, the highest rotation (58°±3.0°) was observed in models with high torsion and high rigidity (7.5 mm−1 net torsion and 254 N·m2 flexural rigidity). No rotation was observed in the absence of torsion. Applying torque to the device during insertion significantly increased stent-graft rotation by an average of 28° across all levels of torsion (p<0.01). Multiple device insertions prior to deployment did not change the observed device rotation. The patient-specific models accurately predicted the degree of rotation seen intraoperatively to within 5°. Conclusion: Insertion technique plays an important role in the degree of stent-graft rotation during deployment. Our model suggests that in vivo correction of device orientation can increase the observed rotation and supports the concept of fully removing the device, adjusting the orientation, and subsequently reinserting. Additionally, increasing iliac artery torsion in the presence of increased vessel rigidity results in stent-graft rotation.

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Section: Discussionmentioning

confidence: 99%

Impact of Insertion Technique and Iliac Artery Anatomy on Fenestrated Endovascular Aneurysm Repair

et al. 2019

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“…BAT is a new technique and developed to deal with severe tortuosity (loops) of arteries in the arterial system during a transradial procedure. It is analogous to similar techniques used to manage difficult fenestrated endovascular grafts 7 or promote passage of catheter-extension type devices down to coronary arteries. 8 In this technique, the PCI balloon is placed across the tip of the catheter and inflated at a low pressure (4-6 atm) while half of the balloon is protruding beyond the catheter.…”

Section: Discussionmentioning

confidence: 99%

Balloon-Assisted Tracking: A Solution to Severe Subclavian Tortuosity Encountered During Transradial Primary PCI

2015

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Radial artery access is preferred over femoral access for primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction because of the reduction in access site complications and mortality associated with the radial artery access. Successful transradial primary PCI requires knowledge of techniques to handle unexpected severe subclavian artery tortuosity. Balloon-assisted tracking (BAT) is one technique developed to negotiate the tortuosity and loops in the upper extremity. However, the use of BAT in dealing with a severe subclavian loop during a transradial primary PCI procedure has never been reported. We described a case of transradial primary PCI with severe subclavian artery loop that was negotiated successfully by the BAT technique.

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“…1 Even in the presence of a re-expanded true lumen and a thrombosed thoracic false lumen after thoracic endovascular aortic repair (TEVAR), there is a continued risk of aortic rupture and a need for additional procedures due to progression of the dissection, aneurysm degeneration, or malperfusion. [2][3][4][5] In 2016, Barbante et al 4 reported a case of relining with a fenestrated endograft (fEVAR) after the PETTICOAT (provisional extension to induce complete attachment) technique for TBAD, underlining the complexity of the procedure. In such challenging cases, planning is sometimes not sufficient to develop an optimal technique of implantation, and advanced endovascular skills are necessary to achieve best results.…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

“…In such challenging cases, planning is sometimes not suffi-cient to develop an optimal technique of implantation, and advanced endovascular skills are necessary to achieve best results. 5 Bailout maneuvers might be required, mainly in case of secondary procedures, anatomical variants, or complex visceral vessel morphology. 6 Our report concerns a case of postdissection thoracoabdominal aortic aneurysm (TAAA) in a patient previously treated with PETTICOAT for acute TBAD, successfully managed with the deployment of a multibranched endograft, overcoming a challenging renal bridging stent deployment with a “floating” stent-graft.…”

Section: Introductionmentioning

confidence: 99%

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Floating Stent-Graft as a Support to Bridge an Unfavorable Renal Artery During Postdissection TAAA Repair Using a Multibranched Thoracoabdominal Endograft

et al. 2020

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Purpose: To report an unusual endovascular technique to manage unfavorable renal artery anatomy encountered in an urgent case of symptomatic postdissection thoracoabdominal aortic aneurysm (TAAA) treated with an off-the-shelf multibranched device. Technique: The technique is demonstrated in a 77-year-old woman who had a history of previous open abdominal aortic aneurysm repair and an emergent procedure to implant a thoracic endograft and an aortic bare Z-stent (PETTICOAT) for acute Stanford type B dissection 7 years prior. The patient presented with a symptomatic, rapidly growing, postdissection TAAA. Endovascular treatment with a Zenith t-Branch was planned. After standard catheterization techniques failed in the left renal artery, a bailout maneuver was utilized to place a “floating” Viabahn stent-graft in the aneurysm sac to create sufficient support to deliver the bridging stent-grafts through the bare stent to the target left renal artery. The procedure was successful in excluding the TAAA and preserving perfusion to all target vessels. No neurological complications occurred. Six-month imaging follow-up confirmed the patency of the bridging stents. Conclusion: Remodeling changes after complex endovascular TAAA procedures often require the use of innovative techniques and materials during secondary procedures. In this case, the presence of a post-PETTICOAT bare aortic stent and hostile target artery anatomy increased the technical difficulty of t-Branch implantation. A “floating” stent-graft could be useful to reach challenging target vessels by providing additional support to bridging stent advancement and deployment.

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Technique of Implantation and Bail-Out Maneuvers for Endovascular Fenestrated Repair of Juxtarenal Aortic Aneurysms

Cited by 18 publications

References 14 publications

Impact of Insertion Technique and Iliac Artery Anatomy on Fenestrated Endovascular Aneurysm Repair

Impact of Insertion Technique and Iliac Artery Anatomy on Fenestrated Endovascular Aneurysm Repair

Balloon-Assisted Tracking: A Solution to Severe Subclavian Tortuosity Encountered During Transradial Primary PCI

Floating Stent-Graft as a Support to Bridge an Unfavorable Renal Artery During Postdissection TAAA Repair Using a Multibranched Thoracoabdominal Endograft

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