eComment. A note on proximal aortic control in the era of increasing endovascular aortic interventions

I read with keen interest the article by Matsagkas and colleagues [1] proposing a bail-out technique in the management of open explantation of endografts with suprarenal fixation. The authors were able to successfully control the aorta in the supracoeliac position by puncturing the endograft after open exposure of the infrarenal aorta, facilitating explantation. The use of balloon occlusion catheters for control of the proximal aorta has been previously described [2], and is standard in the endovascular management of ruptured abdominal aortic aneurysms. The transfemoral route is generally utilized contralateral to the anticipated deployment of the main body; this is preferred in order to avoid potential complications due to risk of injury to the smaller calibre upper extremity arteries, as well as minimizing the stroke risk with manipulations near the aortic arch when a transbrachial or transaxillary route is selected [3]. Unfortunately, the increased emphasis given to training on the endovascular treatment of aortic aneurysms has made younger vascular surgery trainees more uncomfortable navigating the abdomen and the retroperitoneum for quick and adequate open aortic exposure. This is a double-edged situation: more endografts are being placed but fewer individuals feel experienced or comfortable enough to manage open explantation with open supracoeliac control. Although ultimately vascular surgery trainees obtain the necessary operative open case volume, the frequency of repetition of open aortic procedures has decreased, in keeping with current management trends. Therefore, the proposed bail-out technique is quick and efficient, and should be in the armamentarium of any vascular surgeon. Conflict of interest: none declared