The “Periscope” Technique Successfully Lengthens the Distal Landing Zone During TEVAR

Abstract

We describe our early experience with the “periscope” technique to extend the distal landing zone and successfully treat distal thoracic pathology in patients with inadequate distal seal zones near the mesenteric vessels. Four consecutive patients with planned endovascular repair of complex TAA extending near mesenteric and renal arteries were reviewed. In the periscope configuration, which is similar to an upside-down snorkel/chimney approach, parallel stent grafts adjacent to the TEVAR device were placed into the mesenteric and renal vessels from the contralateral femoral approach. Six periscope grafts (4 SMA, 2 in solitary renal arteries) were utilized in four patients (mean age, 72 years). Mean aneurysm diameter was 69.5 mm (range, 59-85 mm), and the “periscope” configuration improved the distal seal zone from a diameter of 45 mm and length of 0 mm to a more appropriate landing zone of 33 mm diameter and 28 mm length. Technical success was 100% and all patients are alive at latest followup (mean, 15.1 months; range, 9-23). The only morbidity was reoperation for femoral access occlusion. Postoperative follow-up imaging revealed all six periscopes to be patent. One small type Ib and one type II endoleak have been observed without aneurysm sac enlargement. All aneurysms have regressed with mean sac change of -4.7 mm. In select high-risk patients opting for an all-endovascular approach of distal thoracic pathology, the “periscope” technique is successful in extending the landing zone into juxtamesenteric and juxtarenal anatomies to provide successful aneurysm exclusion. Long-term follow-up is obviously necessary to assess for continued protection from aneurysm rupture, but at this point it appears to be safe and effective until fenestrated/branched grafts become more widely available.