INNOVATIVE TECHNIQUES

From the Midwestern Vascular Surgical Society

Directional tip control technique for optimal stent graft

alignment in angulated proximal aortic landing zones
Toshio Takayama, MD, PhD, Patrick J. Phelan, MD, and Jon S. Matsumura, MD, Madison, Wisc

ABSTRACT
Angulated anatomy in the aorta, such as tortuous infrarenal aortic necks or steep aortic arches, is a significant challenge
for endovascular aortic repair because it often causes inadequate sealing and fixation, which may lead to treatment
failure. We have developed a technique using off-the-shelf equipment to precisely control the deployment of stent grafts
in challenging landing zones. The key of this technique is to create a through-and-through wire between two access sites
and to use a guiding device over the wire. This technique is best used with stent grafts without nose cones. We present an
endovascular aneurysm repair case and a thoracic endovascular aortic repair case with challenging proximal landing
zones treated by this technique. In both cases, technical success was attained, and follow-up imaging demonstrated
well-aligned stent grafts. Our directional tip control technique is easy and effective. It can be a good technical solution for
endovascular aortic treatment in angulated anatomy. (J Vasc Surg Cases and Innovative Techniques 2017;3:51-6.)

Endovascular treatment of aortic disease is proven to be sheath and stent graft over a stiff wire, the first step is
safe and effective in the descending thoracic aorta and to exchange the stiff wire for a hydrophilic soft wire
infrarenal abdominal aorta.1 Because good sealing is essen- and snare it to make a through-and-through wire
tial for successful endovascular repair, a long and straight between both groin access sites (Fig 1, C). Over the
neck in intact aorta is desirable for the stent graft landing through-and-through wire, a steerable guiding sheath
zone.2 In reality, however, the native aorta of aneurysm pa- or an angulated guiding catheter is advanced until its
tients may be associated with severe angulation in the tip engages the stent graft device tip (Fig 1, D). The stent
aneurysm neck, and angulated anatomy is often a serious graft’s position and direction can be adjusted by rotating
problem for endovascular aneurysm repair (EVAR). A stent the engaged guiding sheath or catheter to an optimal
graft deployed in a severely angulated neck may be position (Fig 1, E). Finally, the stent graft is deployed pre-
deployed in a nonparallel manner, leading to unfavorable cisely orthogonal to the centerline of the aorta (Fig 1, F).
results, such as stent graft collapse, migration, type I endo- We present two cases applying this technique: an
leak, and ultimately late aneurysm rupture.3 To address this abdominal EVAR case and a thoracic endovascular aortic
challenge, we developed the directional tip control tech- repair (TEVAR) case. Institutional review board approval
nique, which requires only basic endovascular skills and was waived because this study involved retrospective
standard equipment and supplies. This technique is best review of two cases.
used with stent grafts without nose cones.

DIRECTIONAL TIP CONTROL TECHNIQUE

EVAR CASE
Fig 1 provides an overview of our directional tip control
A 72-year-old man presented with an infrarenal
technique. After placement of a standard large-bore
abdominal aortic aneurysm, found by screening ultra-
sound. As the aneurysm size was 5.6 cm on computed
From the Division of Vascular Surgery, University of Wisconsin School of
Medicine and Public Health.
tomography (CT) scan, he consented to endovascular
Author conflict of interest: J.S.M. has received research grants from Abbott, treatment.
Cook, Medtronic, Endologix, and W. L. Gore.
Procedure details
Presented as an oral presentation at the Fortieth Annual Meeting of the Mid-
western Vascular Surgical Society, Columbus, Ohio, September 8-10, 2016. 1. Bilateral groin accesses were established by puncture
Correspondence: Toshio Takayama, MD, PhD, Division of Vascular Surgery, of the common femoral artery (CFA) under ultra-
University of Wisconsin School of Medicine and Public Health, 600 Highland sound guidance with a Cook Micropuncture access
Ave, Madison, WI 53792 (e-mail: takayama@surgery.wisc.edu). set (Cook Medical, Bloomington, Ind), followed by
The editors and reviewers of this article have no relevant financial relationships to
deployment of a 10F preclose device, Prostar XL
disclose per the Journal policy that requires reviewers to decline review of any
(Abbott Vascular, Abbott Park, Ill), bilaterally. An 18F
manuscript for which they may have a conflict of interest.
2468-4287
DrySeal sheath (W. L. Gore & Associates, Flagstaff,
Ó 2017 The Authors. Published by Elsevier Inc. on behalf of Society for Vascular Ariz) was advanced on the right side, and a 12F Dry-
Surgery. This is an open access article under the CC BY-NC-ND license (http:// Seal sheath was advanced on the left side. We first
creativecommons.org/licenses/by-nc-nd/4.0/). embolized an accessory left renal artery to prevent
http://dx.doi.org/10.1016/j.jvscit.2017.02.010 type II endoleak.

51
52 Takayama et al Journal of Vascular Surgery Cases and Innovative Techniques
June 2017

Fig 1. Overview of the directional tip control technique. A, Infrarenal abdominal aortic aneurysm with angulated
neck. B, Stent graft device does not fit the angulation by standard approach. C, Exchange the stiff wire to a
floppy wire and snare it to create a through-and-through wire between bilateral groin access sites. D, Insert a
steerable guiding sheath or angulated guiding catheter over the through-and-through wire from contralateral
access site. Engage the tip of the guiding sheath or catheter to the device tip. E, Adjust the position of the
device by manipulating the engaged guiding sheath or catheter so that the device fits the angulation of the
aorta. F, Precisely deployed stent graft.

2. A Gore Excluder main body, RMT281416 (W. L. Gore & the through-and-through wire was applied when
Associates), was inserted from the ipsilateral (right) rotating the device so the wire did not wrap around
groin access over an Amplatz ultrastiff wire (Cook the device. The EVAR main body device was then
Medical). We decided to use the directional tip deployed under precise control. Note that the direc-
control technique for a precise deployment for two tional tip control stabilized both angulation and
reasons: the EVAR device failed to follow the neck longitudinal placement.
angulation, although the angle measured 35 degrees 3. A Gore Excluder leg device, PLC201400, was
(Fig 2, A); and the actual sealing length was short deployed to the left common iliac artery, and a
because of mural thrombus in the aneurysm neck Gore Excluder leg extender device, PXL161407, was
(Fig 2, B). The stiff wire was exchanged to a 260-cm deployed to the right common iliac artery. Comple-
Glidewire (Terumo Medical, Somerset, NJ). A steer- tion aortography demonstrated good exclusion of
able guiding sheath, 6.5F/45-cm Destino (Oscor, abdominal aortic aneurysm. The groin access sites
Palm Harbor, Fla), was inserted from the contralateral were closed by deploying the preclosure sutures.
(left) groin access, and a through-and-through wire
was established between groin access sites by
Brief postoperative course. The patient was discharged
snaring the Glidewire. The EVAR device tip and the
guiding sheath were engaged over the through- the next day after the procedure. A follow-up CT scan
and-through wire (Fig 2, C). The EVAR device was taken 6 months after the procedure demonstrated a
deflected to be precisely parallel to the aortic wall well-aligned stent graft, precisely orthogonal to the
in the infrarenal neck, immediately below the main centerline of the aorta (Fig 2, E); a minimal amount of
left renal artery (Fig 2, D). An appropriate tension to type II endoleak originated from a lumbar artery.
Journal of Vascular Surgery Cases and Innovative Techniques Takayama et al 53
Volume 3, Number 2

Fig 2. An endovascular aneurysm repair (EVAR) case with the directional tip control technique. A, Preoperative
computed tomography (CT) angiogram demonstrates infrarenal neck angle of 35 degrees. B, There was mural
thrombus in the aneurysm neck (arrow). C, A 6.5F steerable guiding sheath engages to the stent graft device tip
over the through-and-through wire (arrow). D, Deflected stent graft device position by manipulating the
engaged steerable guiding sheath (arrowhead). E, Postoperative CT angiogram demonstrates an EVAR stent
graft deployed orthogonal to the aortic centerline, just below the left renal artery.

TEVAR CASE loop technique was used to establish a through-

An 84-year-old man presented with acute chest and and-through wire between brachial and femoral
abdominal pain, radiating to his back, without any sign access sites using 260-cm Glidewire. All stent grafts
of neurologic deficits. CT angiography demonstrated were inserted over this through-and-through wire
acute intramural hematoma in the descending aorta. (tug-of-wire technique4).
Despite medical management, he had persistent pain 4. The CFA sheath was exchanged to a 22F sheath.
and difficult to control hypertension. Repeated CT Aortography was performed in a steep right anterior
oblique projection to identify the celiac artery, and
angiography 2 days later demonstrated a new pseudoa-
the first Gore TAG, TGU282815 (W. L. Gore & Associ-
neurysmal area with extravasation and significant left
ates), was deployed, most distally about 1 cm above
pleural effusion. Because of these radiographic findings the celiac artery. The second Gore TAG, TGU313115,
and persistent symptoms and hypertension, an emer- was deployed in the midthoracic aorta, overlapping
gent endovascular intervention was indicated. A spinal the first graft by 3 cm.
protection protocol including spinal drainage was initi- 5. The third Gore TAG, TGU313110, was advanced to the
ated preoperatively and continued perioperatively. aortic arch zone 2. We used the directional tip control
technique for the third device because of the steep
Procedure details
angulation of the aortic arch (the angle between the
1. The right CFA was punctured under ultrasound centerlines of aortic arch zone 2 and proximal
guidance, and two preclose sutures with ProGlide descending aorta was 70 degrees; Fig 3, A). For the
closure system (Abbott Vascular) were placed. A 12F controlling device, we selected a 6F angled guiding
sheath was inserted into the right CFA. catheter, 55-cm MPA1 (Cordis, Fremont, Calif), which
2. Intravascular ultrasound was used to evaluate the aorta, was inserted from the brachial access over the
and the following strategy was determined: proximal through-and-through wire, and its tip was engaged
landing zone in the aortic arch zone 2 because intramu- to the TEVAR device tip (Fig 3, B). By rotating the
ral hematoma extended to near the left subclavian catheter angle, the TEVAR device was directed toward
artery; total 28 cm of treatment length that required the lesser curve of the arch (Fig 3, C). While stabilized
three stent grafts; 31-mm-diameter stent graft for prox- in this position, the stent graft was deployed precisely
imal landing and 28-mm-diameter stent graft for parallel to the aortic arch (Fig 3, D).
distal landing; and preserved antegrade flow of the 6. Antegrade left subclavian artery perfusion was pre-
left subclavian artery with snorkel stenting. served with snorkel stenting. Completion aortog-
3. The left brachial artery was punctured under ultra- raphy revealed antegrade flow up the left vertebral
sound guidance, and a 7F sheath was placed. Snare artery, no significant compromise of the left
54 Takayama et al Journal of Vascular Surgery Cases and Innovative Techniques
June 2017

Fig 3. A thoracic endovascular aortic repair (TEVAR) case with the directional tip control technique. A, Preop-
erative computed tomography (CT) angiogram demonstrates that the angle between the centerlines of aortic
arch zone 2 and proximal descending aorta was 70 degrees. B, A 5F angled catheter engages to the stent graft
device tip over the through-and-through wire (arrow). Note that the through-and-through wire was between
groin access and left brachial artery access. C, Deflected stent graft device position by manipulating the
engaged catheter (arrowhead). D, Stent graft deployed parallel to the aortic arch without bird-beak configu-
ration. E, Postoperative CT angiogram demonstrates well-aligned stent grafts and patent left subclavian artery
snorkel stent.

common carotid artery, and total exclusion of the left pleural effusion, parallel deployed stent grafts, and
pseudoaneurysm. The groin access site was closed patent left subclavian artery (Fig 3, E).
by deploying the preclosure sutures. Hemostasis of
the left brachial access was completed by manual DISCUSSION
pressure. The effective exclusion of aortic disease by EVAR
requires adequate sealing of the aneurysm neck by
Brief postoperative course. The patient recovered from the stent graft. Unlike direct suture anastomosis in
surgery uneventfully and was discharged to home on conventional open surgery, fixation of a stent graft relies
postoperative day 4. Follow-up CT angiography, per- on the radial force from metallic stents and anchoring
formed 2 months later, demonstrated well-sealed features.5 For this reason, sealing performance of stent
pseudoaneurysm without endoleak, disappearance of grafts is best in a straight, parallel aortic segment;
Journal of Vascular Surgery Cases and Innovative Techniques Takayama et al 55
Volume 3, Number 2

angulated anatomy often prevents precise parallel adjusting the catheter’s curvature. Although insertion
placement in the landing zone, thereby leaving some of a 6F to 7F sheath from the contralateral groin access
segment of the neck unopposed by graft and effectively site is usually safely performed for EVAR procedures, it
shortening the length of seal. This leads to increased risk must be used with caution for TEVAR procedures in
of treatment failure in the short term or long term.2 which brachial access is required. In this situation, a 6F
Antoniou et al reported a systematic meta-analysis of angled guiding catheter is a good substitute as shown
1559 patients, comparing EVAR performed in either in our TEVAR case. An added benefit of the second
favorable or unfavorable proximal neck anatomy. Strik- access is the easy availability of control arteriography
ingly, patients with unfavorable proximal neck anatomy immediately before and during stent graft deployment.
had a fourfold increased risk for development of type I In terms of cost-effectiveness, despite use of those rela-
endoleak and a ninefold increased risk of aneurysm- tively expensive steerable sheaths, we believe that this
related mortality within 1 year of treatment.6 Angulated technique ultimately reduces total cost because precise
anatomy in the thoracic aorta is also a problem. When deployment and maximum purchase of the sealing
the proximal landing zone is in a steeply angulated zone will spare additional, more expensive stent graft
aortic arch, a stent graft is often deployed with “bird- placement.
beak configuration,” an inadequate apposition to the There are some limitations in our technique. First, not
lesser curvature of the arch. This configuration is related all stent grafts would be well suited, particularly those
to high risk of late complications, such as stent graft with nose cones or suprarenal fixation (Cook Zenith
collapse, migration, and type I endoleak.7 Ueda et al re- and Medtronic [Santa Rosa, Calif] Endurant, for
ported that 29% of patients with bird-beak configura- example), because precise deflection of the device tip
tion needed additional treatment, 21% of them had angle may be more difficult with such devices. Second,
stent graft collapse of infolding, and 11% of them died owing to lack of case accumulation, we cannot provide
of an early aorta-related event.7 Creative techniques a clear indication as to when to use this technique. We
have been reported to deal with angulated anatomy hope to publish an indication once we experience
in the landing zone. Park and Kim reported the “kilt enough cases.
technique” for EVAR in a severely angulated infrarenal
aorta.8 A TEVAR graft was deployed in the infrarenal CONCLUSIONS
aorta first to provide a stable landing zone for a subse- Our directional tip control technique is easy and effec-
quent EVAR procedure. Ben Abdallah et al reported a tive. It can be a good technical solution for endovascular
TEVAR procedure involving the aortic arch using a aortic treatment in angulated anatomy.
custom-made proximal scalloped stent graft.9
Our directional tip control technique is versatile; it REFERENCES
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