Endovascular Arch Repair With Triple Inner-Branch Custom-Made Device: A Step-by-Step Approach

Introduction  

Endovascular arch repair is a progressive growth technique that has developed over the last 10-15 years, although open surgery remains the gold standard.  

Clinical Case  

This case involved a 67-year-old male with coronary disease and severe left ventricle (LV) depression. Computed tomography (CT) showed a penetrating aortic ulcer at zones 2 and 3, prompting the decision for an endovascular repair.  
 
Planning  

Accurate analysis of the proximal and distal landing zones, as well as the epiaortic vessels, was essential. Multiplanar reconstruction and modified centerline were important tools for this aim. Iliofemoral access was deemed adequate, and optimal working projections were obtained using 3D volume rendering. 
 
Arch Device  

The arch device was a double-tapered Dacron stent-graft, with a minimum diameter measured at the arch of 42/30/34 mm. It included three inner branches—two antegrade and one retrograde—with a preloaded catheter.  
 
Delivery System  

Different trigger wires, including a spiral wire and both proximal and distal reducing ties were removed progressively using four available rings, allowing for staged deployment. 

Procedure 

Anesthetic Tissues  

The procedure was performed under general anesthesia, with somatosensorial and motor evoked potentials being monitored. No spinal drainage was inserted. 

Access 

Open access to the right axillary artery (RAA) and left common carotid artery (LCCA), as well as echo-guided percutaneous access to the left femoral artery (main access), right femoral artery, and left femoral vein were performed. 

Preparation for Deployment  
Systemic heparinization, was administered, achieving an activated clotting time of 250 to 300 seconds. An effective hypotensive maneuver was checked using a 46 mm Coda balloon positioned in the right atrium inferior vena cava (IVC).A Lunderquist 0.035-inch double extended wire was then positioned at the LV. An ascending aorta-arch angiogram allowed for fusionadjustment. A stiff wire at the ascending aorta (AsAo) from the RAA marked the brachiocephalic trunk (BCT) ostium. 

Deployment of the Main Graft 

Under IVC endoclamping, attention was paid to the endograft radiomarkers and epiaortic ostia while the sheath pullback was fully completed, retrieving the first three rings. 
 
BCT/LCCA Branches 

Using a retrograde access, the inner branch was catheterized by crossing its diamond. Catheter or balloon maneuvers were needed for checking adequate position for the stiff wire through the inner branch. Measurements were taken with a centimeter-calibrated catheter to determine the adequate bridge stent after performing a selective angiogram. The bridge stent was delivered, and ballooning the proximal landing was conducted until reaching the ostium. Then, a selective angiogram was performed to verify adequate perfusion of the target vessel. In this case, a 13/16/90 mm custom-made Dacron stent-graft was implanted at the BCT, along with 2 x 7/57 mm BeGraft peripheral stents at the LCCA were implanted uneventfully. 

Retrieval Delivery System 

A Lunderquist wire was inserted through the preloaded catheter until it reached the AsAo. The fourth ring was then removed. The delivery was exchanged for a 22F x 33 cm Dryseal sheath. A 12Fx 80 cm sheath was advanced until reaching the proximal LSA branch over the AsAo Lunderquist. 

LSA Branch 

A 13/100 mm stent was implanted distally, and an 11/59 mm stent was implanted proximally. 

Final Angiogram 

Left and right anterior angiograms ruled out any endoleaks and complications at the thoracic aorta. 

Postoperative Course/ Follow-Up

The postoperative course was uneventful. An immediate CT scan showed no endoleaks and confirmed patent branches. During follow-up, there were n 
 

References

1. Spanos K, Haulon S, Eleshra A, Rohlffs F, Tsilimparis N, Panuccio G, Kölbel T. Anatomical Suitability of the Aortic Arch Arteries for a 3-Inner-Branch Arch Endograft. J Endovasc Ther. 2021 Feb;28(1):14-19. doi: 10.1177/1526602820953634.
2. Fiorucci B, Tsilimparis N, Rohlffs F, Heidemann F, Debus ES, Kölbel T. How to Confirm Catheterization of Inner Branches in Aortic Endografting: The Universal Flush Test. J Endovasc Ther. 2017 Aug;24(4):539-541. doi: 10.1177/1526602817713305.
3. Spanos K, Haulon S, Tsilimparis N, Rohlffs F, Panuccio G, Kölbel T. Preoperative Measurements and Planning Sheet for an Endograft With 3 Inner Branches to Repair Aortic Arch Pathologies. J Endovasc Ther. 2019 Jun;26(3):378-384. doi: 10.1177/1526602819840329
4. Settembrini AM, Kölbel T, Rohlffs F, Eleshra A, Debus ES, Panuccio G. Use of a Steerable Sheath for Antegrade Catheterization of a Supra-aortic Branch of an Inner-Branched Arch Endograft via a Percutaneous Femoral Access. J Endovasc Ther. 2020 Dec;27(6):917-921. doi: 10.1177/1526602820939936.

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