title: Transseptal ascending aortic access and snare-assisted pull down of the delivery system to facilitate stent-graft passage in the aortic arch during TEVAR.
abstract: OBJECTIVE
  To report the initial use of a transseptal snare-assisted pull-down technique to facilitate stent-graft passage in the aortic arch.
  
  
  METHODS
  A 27-year-old man with Takayasu arteritis presented with large aneurysms in the aortic arch and descending aorta. During thoracic endovascular aortic repair (TEVAR), stent-graft passage through the aortic arch was impossible due to recurrent upward prolapse of the delivery system in the arch aneurysm. The problem was resolved in two steps. First, antegrade ascending aortic access was obtained through a transseptal sheath. The sheath was stabilized by an indwelling transseptal guidewire held taut by a snare in the descending aorta. Next, simultaneously pushing inward on the stent-graft system from the groin and pulling down on the stiff delivery guidewire using another snare introduced through the transseptal sheath moved the wire/delivery system as a unit through the arch. Both aneurysms were successfully excluded; flow into the aortic arch branches was preserved using chimney grafts.
  
  
  CONCLUSIONS
  Use of antegrade ascending aortic access through a stabilized transseptal sheath and snare-assisted pull down of the delivery system to facilitate retrograde stent-graft passage in the aortic arch made it possible to complete the TEVAR procedure in difficult arch anatomy.
authors.affiliation: Department of Cardiology, Christian Medical College, Vellore, India. joseph59@gmail.com
authors.forename: George
authors.initials: G
authors.lastname: Joseph
authors.forename: Edwin
authors.initials: E
authors.lastname: Stephen
authors.forename: Sujith
authors.initials: S
authors.lastname: Chacko
authors.forename: Indrani
authors.initials: I
authors.lastname: Sen
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Joseph
mesh_terms: D000328:Adult; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D054087:Atrial Septum; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation / Q000379:methods*; D006328:Cardiac Catheterization / Q000295:instrumentation; D057510:Endovascular Procedures / Q000295:instrumentation / Q000379:methods*; D004867:Equipment Design; D006801:Humans; D008297:Male; D011474:Prosthesis Design; D011677:Punctures; D015607:Stents; D013625:Takayasu Arteritis / Q000150:complications; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D062666:Vascular Access Devices