Externalized Guidewires to Facilitate Fenestrated Endograft Deployment in the Aortic Arch.
OBJECTIVE
To describe a precannulated fenestrated endograft system utilizing externalized guidewires to facilitate aortic arch endovascular repair and to report its use in 2 patients with challenging anatomy.


METHODS
For distal arch repair, a fenestration for the left subclavian artery (LSA) is made onsite in a standard thoracic endograft tailored to the patient anatomy; it is precannulated with a nitinol guidewire (NGw), which is passed from the femoral artery and externalized from the left brachial artery prior to endograft delivery system introduction over a parallel stiff guidewire. Steps are then taken to remove guidewire intertwining, prevent NGw wrapping around the delivery system, and orient the LSA fenestration superiorly when the delivery system moves into the arch. Gentle traction on the ends of the NGw during endograft deployment facilitates proper fenestration alignment. A covered stent is deployed in the LSA fenestration. The technique is illustrated in a patient with congenital coarctation of the aorta and descending aortic aneurysm. For total arch repair, endograft fenestrations are made for all 3 arch branches; the left common carotid artery (LCCA) and LSA fenestrations are each cannulated with NGws, which travel together from the femoral artery, pass through a LSA snare loop, and are exteriorized from the LCCA. After endograft deployment, the innominate artery fenestration is separately cannulated using right brachial access. Placement of a parallel externalized hydrophilic guidewire passing through the LCCA fenestration (but not the LSA snare loop) and removal of the LCCA fenestration NGw allows exteriorization of the LSA fenestration NGw from the left brachial artery by pulling the LSA snare. Covered stents are deployed in all 3 fenestrations. The technique is presented in a patient with type B aortic dissection.


CONCLUSIONS
Use of the precannulated fenestrated endograft system described is feasible and has the potential to make aortic arch endovascular repair simpler, more reliable, and safer.
Department of Cardiology, Christian Medical College, Vellore, India joseph59@gmail.com.
George
G
Joseph
Department of Vascular Surgery, Christian Medical College, Vellore, India.
Prabhu
P
Premkumar
Department of Cardiology, Christian Medical College, Vellore, India.
Viji
V
Thomson
Department of Cardiology, Christian Medical College, Vellore, India.
Mithun
M
Varghese
Department of Vascular Surgery, Christian Medical College, Vellore, India.
Dheepak
D
Selvaraj
Department of Anesthesiology, Christian Medical College, Vellore, India.
Raj
R
Sahajanandan
D000328:Adult; D000784:Aortic Dissection / Q000175:diagnosis / Q000601:surgery*; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D001017:Aortic Coarctation / Q000150:complications / Q000175:diagnosis; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation* / Q000379:methods; D057510:Endovascular Procedures / Q000295:instrumentation* / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D015607:Stents; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D062666:Vascular Access Devices
aortic arch; arch aneurysm; coarctation of aorta; covered stent; endovascular aneurysm repair; fenestrated stent-graft; fenestration; physician-modified stent-graft; type B dissection