Ascending Aorta Nose-Cone Loop Technique as Bail Out for Precise Branched Endovascular Aortic Arch Endograft Delivery Without Valve Re-Crossing

Abstract

Purpose: To describe a right carotid-femoral through-and-through (T&T) guidewire technique during branched thoracic endovascular aortic arch repair (B-TEVAR) to facilitate endograft delivery in a very tortuous aortic anatomy for a type Ia endoleak (EL) of a previous aortic endograft implantation. Technique: AT&T guidewire was established between the right common carotid artery and the right common femoral artery to facilitate a difficult endograft delivery. Once in the aortic arch, a loop in the ascending aorta was formed to allow the endograft to reach the desired position without losing tension on the guidewire. This maneuver allowed the T&T guidewire to be kept in place until the desired position was reached. The nose-tip of the endograft was curved over the looped guidewire pointing toward the innominate artery without crossing the valve. After endograft deployment, the T&T guidewire was released, and the branches were bridged in a standard fashion. Completion angiography documented correct deployment of the endograft and no sign of type I/III EL. The 1-month computed tomography angiography confirmed the correct deployment. Conclusion: Carotid-femoral T&T guidewire to facilitate endograft delivery in difficult anatomies can be feasible even in B-TEVAR. Possible bailout maneuvers are available if the aortic valve needs to be crossed after endograft delivery. Clinical Impact Endovascular arch repair gains popularity as a valuable alternative, especially in patients considered unfit for open repair. A through-and-through (T&T) guidewire for endovascular arch repair with a landing zone in zone 0 according to Ishimaru is usually performed through the externalization of the femoral guidewire through a transapical access, but this may not always be feasible in frail patients. A right carotid-femoral though-and-through guidewire with a loop formation in the ascending aorta is proposed to achieve the support of a T&T wire to pass tortuous aortoiliac anatomies and access the ascending aorta without the need for aortic valve crossing.