Transseptal Guidewire Stabilization to Facilitate Endograft Delivery During Thoracic Endovascular Aortic Repair of a Giant Tortuous Thoracic Aortic Aneurysm

Figures

• 

  Figure 1. Baseline Case Images (A) Chest x-ray shows a large shadow predominantly occupying the left upper zone (asterisk), suggestive of a large aneurysm. (B) Computed tomography angiography (CTA) upper thoracic axial image shows the anteroposterior and transverse dimensions of a giant aneurysm that compresses the left lung. (C, D) Reconstructed 3-dimensional CTA images. (C) shows a giant tortuous fusiform distal arch and descending thoracic aortic aneurysm, small saccular proximal arch aneurysm (yellow arrow), and occluded left common carotid artery (red arrow). (D) shows occluded left common femoral and bilateral superficial femoral arteries (white arrows).

• 

  Figure 2. Physician-Modification of Arch Endograft (A) Computed tomography angiography 3-dimensional reconstruction image visualizing the superior aspect of the aortic arch perpendicular to the plane of the arch branch ostia (blue ovals). The superior (12 o'clock) position (red line) is marked along the middle of the width of the aortic arch (green lines). The relationship of the arch branch ostia to this line and of the 2 ostia to each other is determined. (B) This relationship is replicated on an appropriate endograft when making fenestrations for the innominate artery (IA-f) and left subclavian artery (LSA-f). A 12 o’clock position is arbitrarily chosen along the apices of adjacent stent struts (red line), and a radiopaque figure-of-8 marker (red arrow) is affixed on an apex to facilitate endograft rotational orientation under fluoroscopy before deployment. A 014-inch nitinol guidewire (dark blue arrow) loops through the two fenestrations and traverses the delivery sheath to emerge from a needle hole at its back end.

• 

  Figure 3. Transseptal Guidewire Stabilization to Facilitate Arch Endograft Delivery (A) Aortic root angiogram after the initial anterograde crossing of the arch-descending aortic aneurysm and creation of a brachial-femoral guidewire loop (white arrow). (B) After transseptal puncture, a balloon-tipped catheter was advanced into the ascending aorta (black arrow), and a coaxial hydrophilic guidewire (white arrow) was exteriorized from the right femoral artery. A bibrachial guidewire loop is seen above (2-tailed arrow). (C) 4-F snare catheter (black arrow) passed through the transseptal sheath into the ascending aorta parallel to and with its loop (white arrow) around the indwelling guidewire. (D) Lunderquist guidewire passed from the right femoral artery deep into the transseptal sheath (white arrow) and caught in the ascending aorta by the 4-F snare (black arrow). (E) Fenestrated endograft delivery system advanced into the ascending aorta with correct rotational orientation as evidenced by figure-of-8 radiopaque marker (arrow) appearing as a straight line facing the outer curve of the arch. (F) Arch endograft deployed with correct rotational orientation and axial position of innominate…

• 

  Figure 4. Fenestration Cannulation and Stenting (A) Stabilization of the arch endograft using a balloon (black arrow) inflated in the IA fenestration after retrograde wiring from the right common carotid artery, before removal of the endograft delivery system (white arrow). (B) 6-F catheter (2-tailed black arrow) riding up over 1 end of the nitinol guidewire (white arrows) that loops through both endograft fenestrations to reach and cross the LSA-f from the RFA; this allowed a parallel indwelling hydrophilic guidewire to travel outside the endograft to reach the IA (black arrows). (C) Tip of hydrophilic guidewire in IA caught by a snare introduced through a 6-F guiding catheter riding over the bibrachial wire loop from LBA to IA (white arrows); pulling this snare and catheter back resulted in the creation of an RFA-LBA wire loop passing straight through the LSA-f. (D) Balloon dilatation of self-expanding covered stent (white arrow) deployed in the LSA-f over the RFA-LBA wire loop (2-tailed black arrow). The IA fenestration has already been stented (black arrow). IA = innominate artery; LBA = left brachial artery; LSA-f = left subclavian artery fenestration; RFA = right femoral artery;

• 

  Figure 5. Rendezvous Technique for Fenestration-Target Vessel Cannulation Used in This Patient (A) Endograft deployed in the aortic arch with fenestrations ‘I’ for the IA and ‘S’ for the LSA. The left common carotid artery was occluded and did not require a fenestration. The figure shows a space around the endograft to better illustrate traversing hardware, but in reality, the endograft was completely apposed to the aortic wall. A nitinol guidewire loop (created during physician-modification of endograft, purple arrows) passes through the 2 fenestrations with both ends emerging from the RFA access. A bibrachial wire loop (blue arrows) was created before endograft deployment. (B) A 6-F catheter (black arrow) riding up the ‘S’ side of the nitinol guidewire loop from the RFA crosses the LSA fenestration and directs a parallel indwelling HGw (red arrow) into the IA. (C) A 6-F guiding catheter (green arrow) riding the bibrachial wire loop from the LBA access reaches the IA and allows a parallel indwelling snare loop (brown arrow) to trap the HGw tip. (D) After removal of the bibrachial guidewire loop and retraction of the femoral catheter, the snare and 6-F guiding catheter are pulled to…

• 

  Figure 6. Completion Angiography After TEVAR (A) Arch aortogram shows TEVAR starting in the midascending aorta with the exclusion of small proximal arch and giant distal arch-descending aortic aneurysms and preservation of flow into the innominate and left subclavian arteries through endograft fenestrations. (B) Descending aortogram shows TEVAR extending past the region of severe tortuosity in the lower descending aorta. There is no evidence of endograft collapse or endoleak. TEVAR = thoracic endovascular aortic repair.

• 

  Figure 7. Computed Tomography Angiography at 6-Month Follow-Up (A) 3-dimensional reconstruction image showing patent and undistorted aortic endografts and fenestration stents in the innominate and left subclavian arteries (arrows). (B) Axial cross-sectional image showing fully thrombosed arch aneurysm (asterisk) and patent, undistorted fenestration stents (arrows).

• 

  Visual Summary. Technique of Transseptal Guidewire Stabilization