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OBJECTIVES: Arch tortuosity and mobility combined with aneurysm pathology may make delivery and precise deployment of thoracic endografts difficult without adjunctive techniques. Guidewire control achieved through brachio-femoral, single-wire technique has been described as an adjunct to deal with this problem. A similar technique, described herein, consists of retrograde left common carotid artery (LCCA) snare capture and control of the stiff guidewire in the ascending aorta, allowing subsequent delivery, positioning, and precise device deployment for Zone 2 landing without compromise of the LCCA. Two cases,a standard case using brachio-femoral and the index case using retrograde LCCA control are presented to demonstrate the utility of adjuntive snare techniques in this clinical setting.
METHODS: Case 1: An 85 yo male presented with symptomatic 10 cm proximal descending thoracic aortic aneurysm in the presence of a tortuous aortic arch. LCCA to subclavian bypass combined with TEVAR was planned. Delivery of a Gore C-TAG^TMdevice could not be achieved due to device and guidewire prolapse into the aneurysm sac. Control of the stiff wire was achieved through use of an endovascular snare and catheter, directed retrograde from the LCCA, in the ascending aorta with application of tension from the femoral position. Precise device deployment was achieved. (Images a and b) Case 2: A 70 year-old female, previously treated with ascending aortic and arch reconstruction by elephant trunk graft (ETG), returned for second stage reconstruction by TEVAR. Cannulation of the ETG was not problematic; however, delivery of the Cook TX-II^TM device, even with use of a buddy wire, could not be achieved. Conversion to brachio-femoral, single guidewire access, facilitated by snare guidewire control and exchange, allowed precise delivery of the graft.
RESULTS: TEVAR was achieved with precise graft deployment in both cases, with no local vascular or central neurologic complications related to adjunctive use of snare-guidewire technique. Both patients enjoyed good outcomes.
CONCLUSIONS: Remote guidewire control from retrograde LCCA access, described first herein, as well as standard dual access-single guidewire control, achieved through use of the endovascular snare, are important adjuncts for safe delivery and device deployment which facilitate TEVAR for reconstruction of arch and proximal descending thoracic aortic pathology in the presence of arch tortuosity, angulation and/or marked aneurysmal dilatation.