Through-and-Through Suture Technique to Stabilize a Sheath in Branched Endovascular Aortic Repair

Abstract

Purpose: To describe a technique to catheterize antegrade branches of a branched thoracoabdominal endograft from a femoral access with the help of standard sheaths and a vascular suture. Technique: The technique is demonstrated in a patient who underwent successful complex thoracoabdominal branched endovascular aortic repair. After the deployment of an aortic endograft with two antegrade branches for the targeted renovisceral vessels, a standard braided sheath was preloaded with a 3/0 polypropylene suture and introduced inside an additional sheath from the groin to the thoracic aorta. Simultaneous gentle traction on the suture as the preloaded sheath was advanced achieved a very stable 180° curve of the proximal end of the sheath. It was possible to selectively catheterize the antegrade branches and respective target vessels sequentially, as well as deploy the planned bridging stents for each branch. Conclusion: The through-and-through suture technique is a helpful tool in branched endovascular aortic repair. It saves time, radiation, and materials; no snare is needed, and it can be preloaded into a sheath.

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

“…We recently described the through-and-through suture technique in bEVAR, which gives superior stability and ease of use in transfemoral bEVAR. 14 A similar technique was utilized in the current case using a brachiofemoral through-and-through wire, which helped provide sufficient stability of the steerable sheath’s deflected tip when tracking the bridging covered stent. This novel approach obviated the need for a cervical cutdown in a patient with a history of bleeding complications and builds on our experience of using steerable sheaths from a common femoral retrograde access in bEVAR to avoid upper extremity access.…”

“…This novel approach obviated the need for a cervical cutdown in a patient with a history of bleeding complications and builds on our experience of using steerable sheaths from a common femoral retrograde access in bEVAR to avoid upper extremity access. 14,15…”

Improved stability of steerable sheath access by femoro-femoral crossover wire in branched stent graft repair of complex thoraco-abdominal aortic aneurysms

“…Steerable sheaths have been successfully used as a secondary option after failed standard cannulation in fenestrated and branched endovascular repair [ 4 ]. Even “self-made” steerable sheaths have been published and can be helpful in bailout situations when no standard steerable sheath is available [ 5 ].…”

Expanding the Anatomical Feasibility of Branched Stent-Grafts in Patients With Variant Visceral Vessel Anatomy

“…This complex anatomy was addressed with a patient-specific custom-made stent-graft with 7 branches to all 4 renal arteries, the common hepatic artery, the splenic artery, and the superior mesenteric artery. The operation was performed with a total femoral approach utilizing steerable sheaths, 5 with technical success and good immediate and 6-month clinical success. The authors should be applauded for this technically demanding and innovational approach.…”

“…Second, the fact that the procedure was performed without adjunctive brachial access is remarkable and highlights the application of steerable sheaths or a through-andthrough suture technique to have a stable platform to access down-going branches from a retrograde femoral approach. 5 While brachial access is widely considered to be benign and of relatively low risk, 15 the possibility of stroke can, at least in theory, be higher with manipulations of the aortic arch and in longer procedures, which can be expected when additional visceral vessels are incorporated. Local complications in the brachial artery itself are also nonnegligible and can carry additional morbidity postoperatively.…”