Endovascular repair of thoracoabdominal aortic aneurysm using the off-the-shelf multibranched t-Branch stent graft Bernardo C. Mendes, MD, Gustavo S.

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Presentation transcript:

Endovascular repair of thoracoabdominal aortic aneurysm using the off-the-shelf multibranched t-Branch stent graft Bernardo C. Mendes, MD, Gustavo S. Oderich, MD Journal of Vascular Surgery Volume 63, Issue 5, Pages 1394-1399.e2 (May 2016) DOI: 10.1016/j.jvs.2016.02.021 Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 1 A, The t-Branch (Cook Medical, Bjaeverskov, Denmark) stent graft with four directional branches (Br). The superior mesenteric artery (SMA) is placed in a fixed point. Note the locations of the celiac axis (blue dots), right renal artery (RRA; yellow dots), and left renal artery (LRA; green dots), demonstrating the spectrum of visceral anatomies suitable for the t-Branch stent graft. B, Standard diameter and length measurements of the device. (Previously published in Endovascular Today, by permission of Mayo Foundation for Medical Education and Research. All rights reserved.) Journal of Vascular Surgery 2016 63, 1394-1399.e2DOI: (10.1016/j.jvs.2016.02.021) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 2 Anatomic criteria for the t-Branch (Cook Medical, Bjaeverskov, Denmark) stent graft. Important considerations are the minimal luminal diameter of 25 mm, ability to incorporate all vessels within a 90° angle to each cuff, and the target vessel diameter of 4 to 8 mm for the renal arteries. (Previously published in Endovascular Today, by permission of Mayo Foundation for Medical Education and Research. All rights reserved.) Journal of Vascular Surgery 2016 63, 1394-1399.e2DOI: (10.1016/j.jvs.2016.02.021) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 3 A, Three-dimensional reconstruction of preoperative computed tomography (CT) angiography demonstrates an extent type III thoracoabdominal aortic aneurysm (TAAA) with a maximum diameter of 7.5 cm in addition to small 6-mm external iliac arteries. B, Intraoperative completion angiography and (C) three-dimensional reconstruction of CT angiography demonstrate successful exclusion of the aneurysm and patent directional branches to the celiac axis, superior mesenteric artery, and right and left renal arteries, with no evidence of endoleaks. Journal of Vascular Surgery 2016 63, 1394-1399.e2DOI: (10.1016/j.jvs.2016.02.021) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 4 The t-Branch (Cook Medical, Bjaeverskov, Denmark) multibranched stent graft is designed with four directional branches for the celiac axis, superior mesenteric artery, and both renal arteries. A, The operation is performed using bilateral femoral and left brachial access; in this case, a right common iliac conduit was used due to small external iliac artery diameter. B, One of the target vessels is catheterized to (C) guide deployment of the multibranched stent graft. D, The distal bifurcated device and iliac limbs are added, and flow is restored to the lower limbs. (Reproduced by permission of Mayo Foundation for Medical Education and Research. All rights reserved.) Journal of Vascular Surgery 2016 63, 1394-1399.e2DOI: (10.1016/j.jvs.2016.02.021) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 5 A, Once all of the aortic components are deployed, flow is restored to the lower extremities, and only a small sheath is maintained in one of the femoral arteries. B, Each branch is accessed via the brachial approach and bridged to the target vessel by placing self-expandable stent grafts. C, A self-expandable bare-metal stent is added to avoid kinking at the distal edge. The repair is completed by placing all of the four side branch stents. D, Note that the right iliac sheath was retrieved to the conduit, which was clamped to restore flow to the right lower extremity. (Reproduced by permission of Mayo Foundation for Medical Education and Research. All rights reserved.) Journal of Vascular Surgery 2016 63, 1394-1399.e2DOI: (10.1016/j.jvs.2016.02.021) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 1 (online only) A, The right renal artery is selectively catheterized. After access is confirmed with limited angiography, a Rosen wire is advanced to the renal artery, followed by placement of a 7F hydrophilic sheath. B, After appropriate lengths are measured, the renal artery is stented using a self-expandable Viabahn (W. L. Gore and Associates, Flagstaff, Ariz) stent graft, (C) typically reinforced by another self-expandable bare metal stent graft, and dilated for its entire length from the target vessel to the cuff. D, Angiography confirms patent right renal artery branch, with no evidence of attachment endoleaks. Journal of Vascular Surgery 2016 63, 1394-1399.e2DOI: (10.1016/j.jvs.2016.02.021) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Supplementary Fig 2 (online only) Deployment of Viabahn (W. L. Gore and Associates, Flagstaff, Ariz) stent grafts into the branches is done carefully to avoid dislodgement. A, Because the deployment mechanism of the Viabahn device is done through a suture string, which when removed, opens a sleeve that constrains the stent, (B) the stent can be pulled out of the intended target vessel. C, A useful technique is to keep the sheath in the middle portion of the stent graft while the stent graft is slowly being deployed to that level. D, The sheath is then retracted, and (E) the deployment is completed. F, If needed, a proximal balloon-expandable covered stent or an additional Viabahn stent graft is deployed to connect to the branch cuff. (Previously published in Endovascular Today, by permission of Mayo Foundation for Medical Education and Research. All rights reserved.) Journal of Vascular Surgery 2016 63, 1394-1399.e2DOI: (10.1016/j.jvs.2016.02.021) Copyright © 2016 Society for Vascular Surgery Terms and Conditions