Directional Control for Precise Deployment of Endovascular Aneurysm Repair and Thoracic Endovascular Aortic Repair in Angulated Anatomy

Abstract

Endovascular stent graft repair of aortic aneurysms has become the standard in most centers. Several anatomic constraints still prevent or compromise the use of this technology. Angulated infrarenal aortic necks or steep aortic arches may result in erratic stent graft deployment with inadvertent branch vessel coverage, inadequate lesion coverage, or bird beaking. We have developed a technique using off-the-shelf equipment to precisely control the deployment of stent grafts in challenging landing zones. Two patients with challenging proximal landing zones were treated by this technique. The first patient, a 72-year-old man, was treated with a Gore Excluder device (W. L. Gore & Associates, Flagstaff, Ariz) for a 5.6-cm infrarenal aortic aneurysm with an angulated neck. A standard J wire was passed through the device, captured with an endosnare, and removed through a Destino sheath (Oscor, Palm Harbor, Fla) in the contralateral groin. The through-and-through wire and sheath allowed the precise deflection of the device along the angulated neck. The device was deployed while deflected. The remainder of the case was unremarkable. The second patient was an 84-year-old man who developed a descending thoracic aortic intramural hematoma with acute enlargement and pseudoaneurysm in the setting of type III aortic arch. In the operating room, two GORE CTAG thoracic stent grafts were built up from the celiac into the proximal descending thoracic aorta. A final proximal stent graft was advanced into approximate position. Left brachial access was established, and a J wire was brought through and through from the stent graft into a 5F MPA catheter in the left brachial sheath. Through a combination of wire traction and forward force on the MPA catheter, the device was precisely positioned onto the lesser curve. The graft was deployed orthogonally at the level of the left carotid. A left subclavian snorkel was planned preoperatively and was placed. In both cases, technical success was attained. Follow-up imaging at 6 weeks in each case demonstrated continuous wall apposition and no endoleak. Anatomic constraints have limited or complicated the use of endovascular stent grafts for some aortic disease. The use of a through-and-through flexible wire and a stiff catheter or sheath allows precise placement in these challenging landing zones.