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Branched Endovascular Thoracoabdominal Aortic Repair Using Staggered Release And Total Transfemoral Approach
Madeline Drake, Guilherme B. Lima, M.D., Emanuel R. Tenorio, M.D., Ph.D., Marina D. Neto, M.D., Ph.D., Aidin Baghbani-Oskouei, M.D., Margaret L. Jackson, M.D., Gustavo S. Oderich, MD.
Univeristy of Texas Health Science Center at Houston, Houston, TX, USA.

Background: Fenestrated-branched endovascular aortic repair (FB-EVAR) has evolved to become a frequently utilized option for patients with thoracoabdominal aortic aneurysms (TAAAs). The traditional technique involves use of brachial access for directional branches. Most recently development of steerable sheaths have allowed total trans-femoral access without need for upper extremity access, potentially reducing the risk of cerebroembolic events. Technique: We present a patient with Extent II TAAA who was treated using staged approach with TEVAR followed by completion BEVAR using a patient specific 4-vessel branch stent-graft. The procedure was performed using total trans-femoral approach using co-axial 12Fr sheath with an 8.5Fr steerable sheath and a locking 0.014 inch guidewire (Figure 1). Because of narrow aortic inner diameter at the level of the celiac axis and superior mesenteric artery, we applied a staggered deployment technique of the diameter-reducing wire, allowing to maximize the working spabe between the aortic stent-graft and the target vessel. A video summarizes the technical pitfalls of the procedure. Conclusion: Total trans-femoral approach using steerable sheaths and staggered removal of the diameter reducing wires is feasible and should be considered in patients with narrow inner aortic diameter and hostile aortic arch anatomy not ideally suited for upper extremity access.


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