Paving the Way From Zone 2 TEVAR to Total Endovascular Arch Repair with Physician-modified Endografts: The Anchor Technique

P0251 

Abstract Submission 

Ugursay Kiziltepe (1), Melike Senkal (2), Ilker Ince (3), Suleyman Surer (4), Ozgur Ersoy (3), Omer Delibalta (5), IBRAHIM DUVAN (3), Kasim Karapinar (6)

(1) Diskapi YBEA Hospital, Çankaya, Select State, (2) N/A, N/A, (3) Etlik Sehir Hastanesi, ANKARA, NA, (4) Etlik Sehir Hastanesi, Ankara, NA, (5) Diskapi YBEA Hospital, ANKARA, NA, (6) Ankara EA Hastanesi, ANKARA, NA

Ugursay Kiziltepe    -  Contact Me
Diskapi YBEA Hospital

Melike Senkal    -  Contact Me
N/A

Ilker Ince    -  Contact Me
Etlik Sehir Hastanesi

Suleyman Surer    -  Contact Me
Etlik Sehir Hastanesi

Ozgur Ersoy    -  Contact Me
Etlik Sehir Hastanesi

Omer Delibalta    -  Contact Me
Diskapi YBEA Hospital

IBRAHIM DUVAN    -  Contact Me
Etlik Sehir Hastanesi

Kasim Karapinar    -  Contact Me
Ankara EA Hastanesi

Ugursay Kiziltepe    -  Contact Me
Diskapi YBEA Hospital

Objectives
Although open surgical repair is gold standard in treatment of patients with arch disease, there are unfit patients for open repair. Current endovascular options are not widely available, have strict IFUs limiting their use widely, and are high-cost. Endovascular arch repair with modifications of standard stent grafts (SG) is attractive due to higher adaptation to anatomy, wider availability, and favorable costs. However, alignment of fenestrations/branches (F/B) with arch vessels is a formidable problem, precluding their widespread use. A reproducible and foolproof technique is needed for this purpose, and we devised the Anchor technique to ease the alignment of fenestrations to arch vessels without interfering with aortic flow and manipulating SGs to prevent cerebral embolization.
Methods:
Following creation of F/Bs on SGs at back table according to spatial relations of arch vessels, a through-and-through wire (TTW) between target and femoral arteries is acquired and used for precannulation of F/B corresponding target artery. After applying diameter-reducing sutures and resheating, SG is advanced to arch with the entrance of TTW to the nosecone and fenestration facing towards the outer curvature. Following partial deployment of the 1/3 of the SG, a non-compliant balloon is advanced through F/B and inflated with half of it in target artery and the rest in SG to create "anchoring" to align and stabilize SG, then the remainder of SG is deployed while diameter-reducing sutures were intact. Using the gap between SG and aorta, the rest of F/Bs were cannulated retrogradely from arch vessels or antegradely from femoral access. Precannulation of F/Bs with .018 nitinol wires extending from femoral access can also expedite antegrade cannulation to avoid carotid cut-down. Following advancing sheats into target arteries and broking diameter-reducing sutures with compliant balloon for full deployment of SG, covered bridging stents were deployed into F/Bs.
Results:
Between August 2020 and November 2023, thirty patients underwent physician-modified TEVAR using Anchor technique. It ensured alignment of F/Bs in all patients without difficulty. Two patients died (6%, 2/30) due to ipsilateral stroke due to a technical error and malperfusion. While LSA was targeted in 25 patients with single F/B, double fenestrated SGs were deployed in 5, in which LCCA+LSA were targeted in three, and IA+ LCCA and LSA+Aberrant RSA were targeted in one patient each. Type 1a endoleak was seen in one and resolved spontaneously in 1st postoperative month. One patient died in the 14th month postoperatively due to pancreatic carcinoma.
Conclusion:
Modifications of SGs allow endovascular treatment of a broad spectrum of arch anatomies provided that adequate landing zone at proximal extent. On the contrary to bypass procedures for arch vessels, F/B SGs preserve anatomic integrity of aortic arch to be used for future interventions. The anchor technique warrants the alignment of F/Bs to at least one of arch vessels, and manipulation of stent graft in the arch is unnecessary. Anchoring balloon fixes partially deployed SG in arch and creates a space to cannulate other arch vessels without interfering with blood flow and causing embolism. The technique is reproducible and can be performed by advanced endovascular specialists for single F/B endografts, while multiple inner and outer branches, in addition to fenestrations, can be created to repair complex arch diseas

Aortic Arch