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• W2071082234 abstract "See related commentary pages 252-3. See related commentary pages 252-3. Placing an endograft into an elephant trunk has recently been established as a promising technique for staged hybrid aortic repair.1Obitsu Y. Koizumi N. Iida Y. Iwahashi T. Saiki N. Watanabe Y. et al.Long-term results of second-stage thoracic endovascular aortic repair following total aortic arch replacement.Gen Thorac Cardiovasc Surg. 2010; 58: 501-505Crossref PubMed Scopus (9) Google Scholar The retrograde navigation of guidewires and delivery systems into severely collapsed or dislocated elephant trunks, however, can be challenging. For such challenging access, a useful approach is the brachiofemoral through-and-through wire technique, which allows accurate delivery of the sheath and devices to the target site.2Lioupis C. Medda M. Inglese L. Thoracic aneurysm repair: managing severe tortuosity with brachiofemoral traction.Catheter Cardiovasc Interv. 2007; 70: 1041-1045Crossref PubMed Scopus (1) Google Scholar This report describes the effective application of this technique to hybrid arch repair. For patients in whom retrograde guidewire access to the distal edge of the elephant trunk is difficult (Figure 1), we use the brachiofemoral through-and-through wire technique as follows. First, a 6F sheath (Medilkit, Tokyo, Japan) is inserted into the right brachial artery, and a 400-cm long, 0.032-inch hydrophilic guide wire (Terumo Medical Corporation, Somerset NJ) is inserted from the right brachial sheath into the aortic arch and antegradely advanced through the elephant trunk. When the guidewire is level with the celiac trunk, it is caught by an Amplatz gooseneck snare catheter (ev3; Endovascular, Inc, Plymouth, Minn) inserted from the femoral artery. The snare catheter is pulled and drawn from the left femoral artery. This technique positions the through-and-through wire from the right brachial artery through the elephant trunk to the femoral artery (Figure 2, A). To reduce the risk of innominate artery injury by tightened guidewire, the 6F brachial sheath is changed to a 6F long sheath (Flexor Ansel KSAW-6.0-18/38-55-RB-ANL2-HC; Cook Medical Inc, Bloomington, Ind) and advanced to the thoracic aortic prosthesis. Then a 22F dry seal sheath (W. L. Gore & Associates, Inc, Flagstaff, Ariz) is inserted from femoral artery, and the TAG endograft (Gore) can then be inserted without difficulty along the guidewire. When the top of the device is passed through the anastomotic site (the junction between branched prosthesis and elephant trunk), the device is held and stabilized by the operator. To position the endograft accurately along the greater curvature of the distal aortic arch, the 0.032-inch guidewire is pulled out and changed to the Lunderquist stiff guidewire (Cook Medical; Figure 2, B). The Lunderquist guidewire is pushed gently to stabilize the position of the endograft during the deployment.Figure 2A, An intraoperative aortogram. The brachiofemoral through-and-through wire (black arrow) is positioned with a snare catheter. White arrows indicate the distal edge of the elephant trunk. B, A Gore TAG prosthesis is inserted into the elephant trunk, and the guidewire is exchanged with a stiff wire for accurate deployment.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Postoperative computed tomography has been used to confirm complete coverage of the aneurysm, with no evidence of endoleaks or endograft migration. Thoracic endovascular aortic repair (TEVAR), which avoids the requirement for a thoracotomy or cardiopulmonary bypass, has demonstrated excellent outcomes in terms of operative mortality and postoperative complications.1Obitsu Y. Koizumi N. Iida Y. Iwahashi T. Saiki N. Watanabe Y. et al.Long-term results of second-stage thoracic endovascular aortic repair following total aortic arch replacement.Gen Thorac Cardiovasc Surg. 2010; 58: 501-505Crossref PubMed Scopus (9) Google Scholar With the introduction of hybrid arch repair, open surgical repair followed by thoracic endovascular aortic repair has become one of the most promising techniques for extended arch pathologies.1Obitsu Y. Koizumi N. Iida Y. Iwahashi T. Saiki N. Watanabe Y. et al.Long-term results of second-stage thoracic endovascular aortic repair following total aortic arch replacement.Gen Thorac Cardiovasc Surg. 2010; 58: 501-505Crossref PubMed Scopus (9) Google Scholar, 3Bavaria J. Vallabhajosyula P. Moeller P. Szeto W. Desai N. Pochettino A. Hybrid approaches in the treatment of aortic arch aneurysms: postoperative and midterm outcomes.J Thorac Cardiovasc Surg. 2013; 145: S85-S90Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar Because most elephant trunks are inserted without fluoroscopic guidance, they are not always in the ideal position or shape. In such cases, the brachiofemoral through-and-through wire technique is extremely useful, because antegradely navigating the guide wire through the elephant trunk is much easier than through a retrograde approach. As described, this technique allows us to navigate devices into a narrow or tortuous prosthesis if the wire is gently tightened from both sides.2Lioupis C. Medda M. Inglese L. Thoracic aneurysm repair: managing severe tortuosity with brachiofemoral traction.Catheter Cardiovasc Interv. 2007; 70: 1041-1045Crossref PubMed Scopus (1) Google Scholar Matsuda and colleagues4Matsuda H. Fukuda T. Tanaka H. Minatoya K. New technique for passage of endograft through problematic arch anatomy.J Thorac Cardiovasc Surg. 2014; 148: 3246-3247Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar have reported a new technique for the smooth passage of the endograft when access to the aortic arch is difficult, though this technique may only be useful for cases in which there has been successful retrograde guidewire access. Furthermore, another type of through-and-through wire technique has been previously reported with transseptal access for antegrade wire introduction.5Joseph G. Stephen E. Chacko S. Sen I. Joseph E. Transseptal ascending aortic access and snare-assisted pull down of the delivery system to facilitate stent-graft passage in the aortic arch during TEVAR.J Endovasc Ther. 2013; 20: 223-230Crossref PubMed Scopus (15) Google Scholar We suggest that transseptal access is extremely effective for advancing endografts into an ascending aorta with a “Gothic” aortic arch; however, it requires complex wire and catheter management. With regard to thoracic endovascular aortic repair for problematic elephant trunks, our technique may be the simplest and most effective method when the retrograde guide wire access is difficult. In our experience, our technique has also been applicable in reinterventions for fractured endografts, as well as for dissections with a narrow true lumen. The brachiofemoral through-and-through wire technique does, however, have limitations. In a patient with severe atheroma in the distal brachiocephalic artery, this technique may lead to serious vascular complications, such as stroke or brachiocephalic artery injury. In such a case, the left brachiofemoral through-and-through wire technique may be considered as the first-line approach if the arch anatomy is favorable. For procedural success, precise preoperative evaluation of aortic arch vessels is essential. In cases with problematic elephant trunk, the brachiofemoral through-and-through wire technique may be considered a useful option." @default.
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• W2071082234 title "Revisiting the brachiofemoral through-and-through wire technique for hybrid arch repair with a problematic elephant trunk" @default.
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