Multi-Branch AOrtic Reconstruction with G-iliac System (BAO-G) Technique in Thoracoabdominal Aortic Aneurysm Endovascular Repair

Central MessageBAO-G technique is a novel technique using iliac-branched devices in endovascular reconstruction for visceral vessels in thoracoabdominal aortic aneurysm.See Commentary on page XXX. BAO-G technique is a novel technique using iliac-branched devices in endovascular reconstruction for visceral vessels in thoracoabdominal aortic aneurysm. See Commentary on page XXX. Total endovascular therapy for thoracoabdominal aortic aneurysms (TAAAs) remains a significant challenge because of the complex anatomical involvement of both the thoracic and abdominal cavities, including the lumbar and visceral arteries.1Khoury M.K. Acher C. Wynn M.M. et al.Long-term survival after descending thoracic and thoracoabdominal aortic aneurysm repair.J Vasc Surg. 2021; 74: 843-850https://doi.org/10.1016/j.jvs.2021.02.048Abstract Full Text Full Text PDF Scopus (5) Google Scholar Here, we introduce multi-Branch AOrtic reconstruction of thoracoabdominal aortic aneurysm with G-iliac system (BAO-G) technique, which uses off-the-shelf iliac-branch devices (IBDs) to reconstruct visceral arteries in a patient with Crawford IV extent TAAAs. Preoperative measurements method and devices used in BAO-G technique are shown in the Appendix E1. In the BAO-G technique, bilateral femoral and left brachial arteries are accessed (Figure 1, A). The modified aortic endograft is released in the predetermined position (Figure 1, B). The first IBD device is introduced via right femoral access to the right limb of aortic endograft, overlapping 3 cm with the aortic endograft limb, and the extending stent graft is inserted though brachial access to reconstruct the superior mesenteric artery (Figure 1, C). The second IBD for celiac artery is rebuilt in the same way as superior mesenteric artery but via contralateral femoral access and left brachial artery (Figure 1, D). In addition, 2 IBDs for reconstruction of bilateral renal arteries are accessed via bilateral femoral arteries, respectively (Figure 1, E and F). The endografts are extended to the bilateral iliac arteries (Figure 1, G). Postdilation and angiography are performed after each branch reconstruction. A 78-year-old female patient was admitted for a 7-cm asymptomatic Crawford extent IV TAAA with a severely tortuous aneurysm neck (Figure 2, A and B). After detailed measurement on computed tomography angiography, total endovascular repair using BAO-G technique was performed because of high surgical risk considering her age and previous coronary artery bypass surgery 2 months before (Figure 2, C). Because of her previous history of lumbar spinal stenosis surgery, preventive cerebrospinal fluid drainage was not performed. Successful reconstruction of 4 visceral arteries was achieved (Figure 2, D). No spinal cord ischemia, visceral ischemia or endoleak was observed at 1-year follow-up (Figure 2, E and F, Video 1). The institutional review board of the Peking Union Medical College Hospital approved the study protocol and publication of data (No. I-24PJ0687; approval date: March 28, 2024). The patient provided informed written consent for the publication of the study data. Available total endovascular repair for TAAA still face problems, such as stent graft accessibility, time-consuming, squeezing, gutter leak between stent grafts, and high requirements of endovascular techniques for cannulation to visceral branches.1Khoury M.K. Acher C. Wynn M.M. et al.Long-term survival after descending thoracic and thoracoabdominal aortic aneurysm repair.J Vasc Surg. 2021; 74: 843-850https://doi.org/10.1016/j.jvs.2021.02.048Abstract Full Text Full Text PDF Scopus (5) Google Scholar, 2Motta F. Oderich G.S. Tenorio E.R. et al.Fenestrated-branched endovascular aortic repair is a safe and effective option for octogenarians in treating complex aortic aneurysm compared with nonoctogenarians.J Vasc Surg. 2021; 74: 353-362.e1https://doi.org/10.1016/j.jvs.2020.12.096Abstract Full Text Full Text PDF Scopus (25) Google Scholar, 3Heslin R.T. Sutzko D.C. Axley J. et al.Association between thoracoabdominal aneurysm extent and mortality after complex endovascular repair.J Vasc Surg. 2021; 73: 1925-1933.e3https://doi.org/10.1016/j.jvs.2020.10.025Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 4Wang M. Yao C. Yin H.H. et al.Endovascular treatment of ruptured or symptomatic thoracoabdominal and pararenal aortic aneurysms using octopus endograft technique: mid-term clinical outcomes.J Endovasc Ther. 2023; 30: 163-175https://doi.org/10.1177/15266028221075236Crossref Scopus (2) Google Scholar, 5Zeng Z. Zhao Y. Ainiwaer A. et al.Physician-modified branched double-trunk stent-graft (PBDS) for thoracoabdominal aortic aneurysm.Heart Lung Circ. 2021; 30: 896-901https://doi.org/10.1016/j.hlc.2020.10.022Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar The BAO-G technique provides a novel solution to these problems. First of all, it uses an off-the-shelf aortic and iliac-branched devices and only requires slight modification, and it also provides a feasible solution with multiple remedial ways for a wide extent of anatomy in TAAAs, which increases the accessibility of suitable devices and shortened time cost. Second, the visceral vessels are reconstructed via one side, providing continuous blood flow to abdominal organs and the spinal cord during the operation, which prevents long-term intraoperative ischemia. Third, it avoids extrusion of stent grafts and gutter leak and provides an overlap of at least 3 cm to prevent type III endoleak. In addition, visceral branch cannulation along the blood flow improves the success rate of reconstruction, which shortens the learning curve. This technique has been performed in 5 patients, and so far all patients survived. Except for this patient, the other 4 patients received protective cerebrospinal fluid drainage routinely before the procedure, and no spinal cord ischemia was recorded in these 5 patients. The BAO-G technique could be a novel choice for TAAA endovascular therapy. It is easy to reconstruct visceral branches and is available using off-the-shelf IBDs. Long-term results need to be confirmed in a larger sample size cohort.