title: Branched grafts for thoracoabdominal aneurysms: off-label use of FDA-approved devices.
abstract: OBJECTIVE
  To report off-label use of approved off-the-shelf endografts with no modification to the devices for the management of thoracoabdominal aneurysms (TAAA).
  
  
  METHODS
  The parallel endograft octopus technique is demonstrated in a 68-year-old woman with a past history of open TAAA repair with a patch reimplant of the visceral vessels who now presented with back pain. Non-contrast computed tomography revealed a 6.8-cm aneurysm of the visceral segment involving the celiac trunk, superior mesenteric artery (SMA), and right renal artery. As she was at high risk for redo surgery due to significant pulmonary dysfunction, she was an ideal candidate for a branched graft, but she could not travel to an investigational site for a custom graft. At surgery, 4 sheaths were introduced, 2 retrograde (18-F DrySeal) and 2 (8-F) antegrade, via the femoral arteries. The 18-F sheaths on both sides were connected to the 8-F sheaths for continued limb perfusion. Via an axillary conduit, a 12-F, 80-cm sheath was introduced into the proximal thoracic aorta over a stiff wire. Subsequently, two 28-mm Excluder endografts were introduced via the bilateral 18-F femoral sheaths and positioned side by side in the descending thoracic aorta such that the lower end of the Excluder limbs were positioned ≥2 cm above the target visceral vessels. Viabahn stent-grafts were then deployed in the celiac axis, SMA, and right renal artery from the axillary conduit. Subsequently, a 23-mm Excluder was deployed within the distal end of the upsized limb and extended to both common iliac arteries. Imaging at 6 months demonstrated no endoleaks, with good flow to all visceral vessels.
  
  
  CONCLUSIONS
  The parallel endograft octopus technique described here, which has been applied successfully in 9 cases thus far, is a relatively simple method using currently available devices with no requirement for device modification or customization. Although this technique shows promise, long-term data will be required to prove efficacy. This technique demonstrates a concept for future development of branched graft technology.
authors.affiliation: Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA. kkasira@emory.edu
authors.forename: Karthik
authors.initials: K
authors.lastname: Kasirajan
mesh_terms: D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D018795:Device Approval; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation*; D005260:Female; D006801:Humans; D018579:Patient Selection; D011474:Prosthesis Design; D015607:Stents; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014481:United States; D014486:United States Food and Drug Administration