Technical pitfalls and initial clinical experience using femoral staggered multibranch thoracoabdominal aneurysm repair technique

Total transfemoral approach may be challenging in patients with narrow aortic lumens. We describe a novel total femoral staggered multibranch thoracoabdominal aortic aneurysm repair technique (FEM-SMART) to facilitate target vessel catheterization in this population. FEM-SMART is performed using a standard off-the-shelf multibranch stent graft via a total transfemoral approach. The endograft is partially deployed to the level of the celiac axis directional branch, which is selectively catheterized via contralateral femoral access using a steerable sheath. Subsequently, staggered endograft deployment, sequential catheterization of directional branches, and target vessel stenting are performed, starting with the superior mesenteric artery, followed by the renal arteries. The infrarenal segment of the endograft is then partially deployed and catheterized using the steerable sheath, which is reformed and used for catheterization and stenting of the celiac axis. Diameter-reducing ties are released, and the repair is completed in a standard fashion. Seven patients (5 males; median age, 76 years; interquartile range, 56-83 years) were treated using FEM-SMART. Technical success was 100%. There were no target vessel instabilities or major complications at a median follow-up of 2 months (interquartile range, 1.5-4.5 months). These results support FEM-SMART as a feasible technique that enables a total transfemoral approach in patients with narrow aortic lumens.