Abstract
The branched stent-graft is custom-made (Cook Medical, Brisbane, Australia) and is available in diameters between 34 and 46 mm, with a covered length of 250 mm. The device is loaded into a Flexor sheath with a diameter of 20 to 24 French (F). The introducer has an inner nitinol cannula and is precurved. The device allows a total endovascular treatment of pathologies of the aortic arch which represents one of the most anatomically complex segments of the thoracoabdominal aorta due to the plurality of supra-aortic branch configurations, the highly variable curvature and the potential of severe neurological complications. The chapter focus on a step-by-step presentation of all important procedural steps in case of treatment of an aortic arch aneurysm by a branched custom-made device.
Keywords
aortic arch aneurysm, branched custom-made device, complex aortic disease, complex endovascular aortic repair, supraaortic vessels
The aortic arch is one of the most anatomically complex segments of the thoracoabdominal aorta because of the plurality of supra-aortic branch configurations and highly variable curvature. Endovascular treatment of aortic arch aneurysms using branched stent-grafts was reported initially by Inoue et al. in 1999. Their device consisted of a unibody graft with up to three limbs that were snared and pulled into each of the aortic trunk vessels.
In 2003, Chuter et al. described a modular branched stent-graft implanted proximally into the ascending aorta and distally into the innominate artery (IA) and descending thoracic aorta. However, this method has fallen out of favor due to various issues, including delivery of the device through the IA, size constraints, and relatively high stroke and mortality risk, approaching 30%. These factors, along with the success achieved in the thoracoabdominal aorta with branched stent-graft repair of thoraco-abdominal aneurysms, led to a refined design and revised thinking about the method of device introduction, resulting in a novel multibranched stent-graft intended for transfemoral insertion.
The branched stent-graft is custom-made (Cook Medical, Brisbane, Australia) and is available in diameters between 34 and 46 mm, with a covered length of 250 mm. The device is loaded into a Flexor sheath with a diameter of 20 to 24 French (F). Fig. 15.1 presents the curved delivery system.
The introducer has an inner nitinol cannula and is precurved. A notch in the dilator tip is aligned with the outer curve of the introducer and graft. The advantage of this novel introducer is that it automatically orients itself properly during placement into the arch without any rotational manipulation.
The graft is constructed with two side-branches ( Fig. 15.2 ). Theoretically, a third branch could be added for the left subclavian artery (LSA). Usually, the branch for the left common carotid artery (LCCA) is an 8-mm side branch situated distally within the body of the graft at the 11:30 clock position, and the branch for the IA is a 12-mm branch situated proximal at the 12:30 position.
The first case with this device was performed in 2009 and involved a branched graft with external, funnel-shaped branches to facilitate their cannulation. In addition, the proximal stent was modified to incorporate the Cook Medical Pro-Form technology, so that proximal wall apposition was ensured. Gold markers indicated the location of side branches and the aspect of the graft to be aligned to the greater curve of the arch. Two sets of gold markers are placed at the branch entries: quadruple linear markers at the proximal edge of the innominate branch and the distal edge of the carotid branch entries, and double markers at the distal edge of the innominate branch and the proximal edge of the carotid branch entries. The stent-graft tapers at the site of the side-branch openings to provide more space to accommodate the branches.
Stent-grafts, such as Fluency (Bard Peripheral Vascular, Tempe, Arizona, USA) or Viabahn (W.L. Gore & Associates, Flagstaff, Arizona, USA), are used to bridge from the LCC side-branch to the LCCA. These bridging grafts require optional support with self-expanding stents. Because of the larger diameter of the IA, custom-made bridging limbs (Cook Medical) are used to bridge from the IA to its side branch ( Fig. 15.3 ). These bridging limbs use ‘low-profile” fabric and nitinol stents to ensure that the grafts can be loaded into a 14F flexor sheath.
