Technical video of endovascular repair of chronic postdissection thoracoabdominal aortic aneurysm using a five-vessel preloaded fenestrated-branched stent.

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Technical video of endovascular repair of chronic postdissection thoracoabdominal aortic aneurysm using a five-vessel preloaded fenestrated-branched stent graft Aleem K. Mirza, MD, Emanuel R. Tenorio, MD, PhD, Jussi M. Kärkkäinen, MD, PhD, Pinar Ozbek, BS, Gustavo S. Oderich, MD Journal of Vascular Surgery Volume 69, Issue 1, Pages 296-302.e1 (January 2019) DOI: 10.1016/j.jvs.2018.09.042 Copyright © 2018 Society for Vascular Surgery Terms and Conditions

Fig 1 A, Preoperative anatomy with previous ascending aortic repair and infrarenal endovascular aneurysm repair, with aneurysmal degeneration of the aortic arch and an extent II dissecting thoracoabdominal aortic aneurysm (TAAA). B, Stages I and II of repair with resuspension of the aortic valve, redo ascending and arch repair, frozen elephant trunk technique, and thoracic stent graft extension. C, Establishment of left brachial-femoral access with snaring of a through-and-through wire. D, Advancement of the delivery system over the brachial- femoral wire, with externalization through the left brachial sheath. Illustration of the novel low profile preloaded guidewire system with (E) externalization of delivery system through the brachial sheath (F) unsheathing of top-cap of the delivery system exposing the preloaded wires (G) cutting of preloaded wire loops (H) to establish four preloaded wires. Image used with permission of Mayo Foundation for Medical Education and Research. All rights reserved. Journal of Vascular Surgery 2019 69, 296-302.e1DOI: (10.1016/j.jvs.2018.09.042) Copyright © 2018 Society for Vascular Surgery Terms and Conditions

Fig 2 Sequential target vessel cannulation with (A) external labeling of preloaded guidewires at the brachial sheath, (B) followed by sequential access of the celiac axis (CA), superior mesenteric artery (SMA), and renal arteries with 0.014, 0.018, and 0.035 wires respectively. (C) Advancement of a 7F sheath through the right renal fenestration. LR, Left renal; RR, right renal. Image used with permission of Mayo Foundation for Medical Education and Research. All rights reserved. Journal of Vascular Surgery 2019 69, 296-302.e1DOI: (10.1016/j.jvs.2018.09.042) Copyright © 2018 Society for Vascular Surgery Terms and Conditions

Fig 3 Distal extension of the repair with an inverted limb device (A) with cannulation of the contralateral gate (B) and contralateral limb deployment. Image used with permission of Mayo Foundation for Medical Education and Research. All rights reserved. Journal of Vascular Surgery 2019 69, 296-302.e1DOI: (10.1016/j.jvs.2018.09.042) Copyright © 2018 Society for Vascular Surgery Terms and Conditions

Fig 4 (A) Sequential vessel stenting (B) with an intra-aortic stent flaring to 10 mm. (C) iCast stents (Atrium, Hudson, NH) are used for the main renal arteries, a bare metal stent for the right accessory renal artery, and Fluency Flare stent grafts (Bard Peripheral Vascular, Tempe, Ariz) for the celiac and superior mesenteric artery (SMA). Image used with permission of Mayo Foundation for Medical Education and Research. All rights reserved. Journal of Vascular Surgery 2019 69, 296-302.e1DOI: (10.1016/j.jvs.2018.09.042) Copyright © 2018 Society for Vascular Surgery Terms and Conditions

Fig 5 Summary of a staged hybrid approach to an extent II thoracoabdominal aneurysm with chronic type B dissection. Image used with permission of Mayo Foundation for Medical Education and Research. All rights reserved. Journal of Vascular Surgery 2019 69, 296-302.e1DOI: (10.1016/j.jvs.2018.09.042) Copyright © 2018 Society for Vascular Surgery Terms and Conditions

Supplementary Fig (online only) A novel, low-profile preloaded guidewire delivery system demonstrating route of preloaded wires. (A) The fenestrated branched stent graft with branches for the celiac axis (CA) and the superior mesenteric artery (SMA), and fenestrations for the three renal arteries. (B) The distal 7F nose cone of the delivery system designed to be inserted from femoral access and exit through the brachial sheath. (C) The unsheathing of the distal nose cone to reveal the preloaded wires. (D) Long delivery system designed to enter via femoral access and exit via the upper extremity sheath. (E) Two loops of preloaded wires housed in the distal nose cone, which is completely unsheathed. (F) Schematic of the route of the two preloaded wires. Journal of Vascular Surgery 2019 69, 296-302.e1DOI: (10.1016/j.jvs.2018.09.042) Copyright © 2018 Society for Vascular Surgery Terms and Conditions