Use of a Steerable Sheath for Completely Femoral Access in Branched Endovascular Aortic Repair Compared to Upper Extremity Access

Abstract

Purpose To compare bridging stent graft (BSG) implantation in downward oriented branches in branched endovascular aortic repair (bEVAR), using a commercially available steerable sheath from an exclusively femoral access (TFA) with traditional upper extremity access (UEA). Methods In a retrospective cohort study, 7 patients with 19 branches in the TFA cohort received BSG insertion using the Medtronic Heli FX steerable sheath from a femoral access, and 10 patients with 32 branches in the UEA cohort from a brachial approach. Technical success, total intervention time, fluoroscopy time, branch cannulation time, and complication rate were recorded. Results Technical success was 19/19 branches in the TFA and 31/32 in the UEA cohort. The mean branch cannulation time was considerably shorter in the TFA group (17 vs. 29 min, p = 0.003), and total intervention time tended to be shorter (169 vs. 217 min, p = 0.176). Conclusion Using a commercially available steerable sheath allowed successful cannulation of all branches in this cohort and was associated with significantly shorter branch cannulation times. Potentially, this technique can lower the stroke and brachial puncture site complication risk as well as reduce total intervention time and radiation dose. Level of Evidence 2b, retrospective cohort study.

A review on the use of steerable sheaths in complex endovascular aortic repair

“…The large diameter sheath also minimises the friction during advancement of the bridging stent grafts even in tight curves. 9 F I G U R E 1 An example of a patient undergoing a four-branch custom-made branched endovascular aneurysm repair. The target visceral vessels were cannulated and stented using steerable sheaths from a total transfemoral approach serially to (A) the left renal artery, (B) the super mesenteric artery, (C) the right renal artery and (D) the celiac artery.…”

“…It has a stable curvature to allow implantation of bridging stent graft without the need of adjunct techniques such as through‐and‐through wires or occlusion balloons. The large diameter sheath also minimises the friction during advancement of the bridging stent grafts even in tight curves 9 …”

Fenestrierte und verzweigte endovaskuläre Aortenprothesen

“…Erfahrungen in unserem Zentrum zeigen, dass mit Hilfe der neueren steuerbaren Schleusen (z. B. Heli FX, Medtronic) eine Sondierung auch fast immer von einem rein femoralen Zugang erfolgen kann, was zu einer signifikanten Verkürzung der Sondierungszeit führt [ 9 ].…”

Endovaskuläre Aortenreparatur bei Endoleaks

“…Die sekundäre Implantation eines Iliac side branch nach endovaskulärer Aortenversorgung ist aufgrund der fehlenden Möglichkeit eines kontralateralen Zugangs etwas aufwendiger und erfordert zumeist einen brachialen Zugang für die Implantation des A.-iliaca-externa-Beinchens. Eine rein unilateral-femorale Implantation ist durch die Verwendung moderner steuerbarer Schleusen in Einzelfällen schon gelungen [ 30 ].…”