Two Wire System and Modified Olive Tip to Facilitate Implantation of Fenestrated TEVAR in Patient with Proximal Descending Aortic Pathology: First Two Cases

Figures

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  Fig. 1. Schematic design of the fenestrated stent graft with two wire system. A Schematic figure of the Fenestrated stent graft. B The whole length of the stent graft and delivery system. C Proximal part of the system: (1) Central hole of the olive tip, from which the super stiff wire is inserted, (2) Side hole of the olive tip. The side branch wire that is positioned in the left LSA is inserted to the delivery system from this hole, (3) Fenestration hole of the stent graft and (4) Stent graft. D Distal part of the system: (1) Central hub, from which the central wire (stiff wire) will come out of the delivery system, (2) Side hub, from which the side wire will come out of the delivery system and (3) Delayed deployment system. E Photograph of Proximal part of the system: (1) Lunderquist guide wire loaded to central hole of the olive tip, (2) Hydrophilic guide wire loaded to side hole of the olive tip and (3) The small tube connecting the side hole of the olive tip and the side hub at the end of delivery sheath. F Photograph of Proximal part of the system: (1) Lunderquist guide wire exit the delivery sheath through the central hub and (2) Hydrophilic guide wire exit the delivery sheath…

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  Fig. 2. Schematic step by step implantation technique of fenestrated stent graft with two wire system. A Hydrophilic guide wire is snared and externalize through left brachial artery. B Lunderquist guide wire is placed at the ascending aorta. C After loading the Lunderquist guide wire to the central hole and the hydrophilic guidewire to the side hole of the olive tip, the stent graft delivery system is advanced to the descending aorta. D Pre-deployment position of the stent graft with the hydrophilic/LSA wire is oriented superiorly. E Deployment of the stent graft with the hydrophilic/LSA wire runs from the LSA to the fenestration of the stent graft

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  Fig. 3. Step by step implantation technique of fenestrated stent graft with two wire system. A After surgical arteriotomy of the right femoral artery and percutaneous placement of left brachial sheath (6F Sheath, Terumo, Japan), two guidewires were introduced from the femoral artery: one guide was advanced to ascending aorta (Lunderquist, stiff Guidewire), the second (260 cm, Terumo, Guidewire) was captured and externalized from left brachial artery. The third wire was another Terumo hydrophilic wire placed in asceding aorta from left brachial artery that serves as protective wire and access for pigtail insertion. B The measuring pigtail catheter was advanced over the guide wire from left brachial artery. Catheter tip was located at ascending aorta. C The aortogram shows large thoracic aortic aneurysm (TAA) in proximal descending aorta, very close to left subclavian artery origin. Anatomic variation in aortic arch: common trunk of right brachiocephalic artery and left carotid artery. The length of zone 2 is about 1 cm. D The 34 × 130 mm stent-graft delivery system was advanced over two wires: one is in ascending aorta, another one is in left brachial artery. E Fenestration hole marker is…

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  Fig. 4. Aortic CT of the first patient before (A) and 6 months after the fenestrated TEVAR (B). Patency of the LSA stent is maintained after 6 months. No endoleak was observed

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  Fig. 5. Aortic CT of the second patient showing type B aortic dissection (A) with mal-perfusion syndrome due to partial/total occlusion of the celiac trunk, superior mesenteric artery (B), renal artery and distal abdominal aorta (C). Aortogram before (D) and after the fenestrated TEVAR (E). The entry tear was located very close to the LSA. After implantation of the fenestrated stent graft, the LSA stent was patent, the entry tear was closed and the false lumen was excluded. 6 months follow up CT showed patent LSA stent and partial thrombosis of the false lumen (F)