New Technical Approach to Overcome Anatomical Challenges During Branched Endovascular Aortic Repair with off-the-Shelf M
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COMMENTARY
COMMENTARY
New Technical Approach to Overcome Anatomical Challenges During Branched Endovascular Aortic Repair with off-the-Shelf Multibranched Stent-Grafts: Are We Sequentially and Progressively Scraping the Sky? Commentary on ‘‘Sequential catheterization and progressive deployment of the Zenith tBranchTM device for branched endovascular aortic aneurysm repair’’ Mario D’Oria1
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Sandro Lepidi1
Received: 26 September 2020 / Accepted: 3 October 2020 Ó Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2020
Branched endovascular aortic repair (BEVAR), which nowadays represents the first-line option for treatment of thoracoabdominal aortic aneurysms (TAAA), is typically performed using patient-specific devices, whose time delay for manufacturing has limited their use to elective cases. Available endovascular alternatives to avoid such delay in urgent cases include off-the-shelf multibranched endografts, with significant clinical experience reported for the Zenith t-Branch device (Cook Medical, Bloomington, Ind) [1]. In their study, Malekpour et al. describe a novel technique of sequential catheterization and stenting amid progressive deployment (SCAPED) for the t-Branch device [2]. In brief, the t-Branch is deployed only enough to release the proximal target vessel (TV) cuff, with the remaining branches and the distal edge remaining constrained within the delivery sheath while the TV is selected and accessed. Once all TV are secured with a stiff guidewire, the endograft is fully deployed and the constraining wires are removed, while the procedure will continue in standard fashion. Use of the SCAPED approach in 18 consecutive patients (June 2016-April 2019) resulted in 100% technical success rate. Use of the SCAPED technique can certainly be a valuable adjunct, particularly in challenging scenarios that would represent relative contraindications to use of the & Mario D’Oria [email protected] 1
Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Medical School and Hospital of Trieste ASUIGI, Strada di Fiume 447, 34149 TriesteTS, Italy
Zenith t-Branch including small aortic lumen or unfavorable TV configuration. Indeed, this novel technique might result in reduced device (mal)rotation and increased (re)positioning freedom, thereby aiding to overcome some anatomical hazards such as narrow aortic diameter or presence of severe angulation/tortuosity/stenosis of the TV, by allowing more controlled release of the stent-graft and progressive ‘‘one-at-a-time’’ access to the TV. A potential shortcoming of the SCAPED technique could include the longer time to deploy the t-Branch device while TV are catheterized, thereby increasing ischemic times in the ipsilateral lower extremity and pelvis, which are well-recognized risk factors for postoperative spinal cord ischemia (SCI) [3]. In their series, Malekpour et al. reported only one case (5%) of post-procedural SCI, but none of the pa
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