Balloons are currently used to expand vascular stent graft once deployed, to stabilize primary graft and overlap attachment. Several models are available on the market; there are some differences in balloon material which can be found in polyurethane or latex. Diameters have a very wide range from 10 to 46 mm; some models are semicompliant and offer more than one size to adapt to various anatomies; compliant balloon instead can expand to the desired diameter up to 46 mm with only one size.

An alternative type, specific for the thoracic aorta, is represented by a particular compliant tri-lobed polyurethane balloon catheter (Gore Tri-lobe). The lobed design of the balloon catheter allows for inflation without complete blockage of aortic blood flow.

In all these devices, a guidewire lumen allows introduction of a 0.035 in. diameter guidewire for over-the-wire access, and radiopaque markers indicate the balloon edges.

All the procedures are performed in the operating room, using a portable digital C-arm image intensifier with road-mapping capabilities.

Intraoperative trans-esophageal echocardiography (TEE) monitoring is routinely used during all the thoracic procedures. In our experience TEE is useful under many aspects as it allows to double check for the most appropriate landing zone of the endograft (in particular when the LSA origin has to be spared). As a second instance TEE is capable of documenting thrombosis or the presence of slow flow inside the aneurysm sac after deployment of the endograft, thus avoiding repeated angiography and the use of high doses of contrast media [3].

For TEVAR our preferred choice is to perform the endovascular procedure, when not contraindicated, under general anesthesia. In selective cases, depending of the patient general condition and comorbidity, we also perform local anesthesia, avoiding as frequent as possible, spinal anesthesia. The opportunity to perform local or general instead of spinal anesthesia allows us to have early diagnosis of spinal cord injury that may be obtained by early awakening and neurological conditions evaluation.

For EVAR instead, we perform the endovascular procedure preferably under spinal or local anesthesia, but we also perform general anesthesia in selected cases.

Patients are placed in the dorsal decubitus position, and the operative field is prepared and draped. It is mandatory that the operating field is prepared in such a way to allow a laparotomy for access and abdominal aorta and/or iliac arteries control that may be useful in such cases of iliac tortuosity and severe calcifications that could avoid stent graft navigation.

The common femoral artery is normally exposed through a small inguinal incision.

In case of extremely diseased (calcific) bilateral external iliac arteries, or small-caliber vessels, we use the common iliac through a paramedian extraperitoneal approach as the access site; we use to directly puncture the artery through a purse string or we perform a surgical conduit to avoid the extremely diseased iliac axis. In rare cases the abdominal aorta has been used as the access site, with direct puncture and then closure with a purse-string suture. Surgical conduits are mainly used in female patients due to generally smaller access vessels [4] (Fig. 16.1).