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Off-the-Shelf Multibranched Endograft


To overcome the delay of custom manufacturing and to offer an off-the-shelf solution for use in urgent conditions, a new device was designed, the t-branch thoracic endograft. This off-the-shelf device has an introduction delivery system that consists of a 22-French (22F) Flexor introducer sheath (7.3-mm inner diameter [ID] and 8.5-mm outer diameter [OD]) and a Captor hemostatic valve (Cook Medical, Bloomington, Indiana, USA). The system has a fixed proximal diameter of 34 mm and a distal diameter of 18 mm. Cook Medical provides a universal distal body at four different sizes, with proximal diameter (D) always 22 mm; lengths (L) of 81, 98, 115, and 132 mm; and 20F delivery system ( Fig. 12.1 ).

FIG. 12.1
Features of the t-branch device. SMA, Superior mesenteric artery; coeliac, celiac.

From Bisdas T, Donas KP, Bosiers MJ, et al. Custom-made versus off-the-shelf multibranched endografts for endovascular repair of thoracoabdominal aortic aneurysms. J Vasc Surg 2014;60(5):1188.

The device was created to overcome the limitations of the custom-made multibranched endograft. Consequently, symptomatic and ruptured thoracoabdominal aortic aneurysms (TAAAs) can now be treated with this device.

Anatomic Requirements

  • 1.

    Proximal to aneurysm. The device requires a 25-mm-long segment of nonaneurysmal thoracic aorta for proximal fixation, with an angle of less than 90 degrees relative to the long axis of the aneurysm, length of at least 25 mm, and diameter measured outer wall to outer wall no greater than 30 mm and no less than 24 mm. Alternatively, the device may be attached to a preexisting thoracic endovascular graft.

  • 2.

    Visceral vessel anatomy

    • a.

      Four indispensable arteries

    • b.

      Aortic diameter greater than 25 mm at the region of the branches

    • c.

      Target vessel accessible from antegrade approach

    • d.

      Celiac and superior mesenteric artery (SMA) 6 to 10 mm in diameter

    • e.

      Renal arteries 4 to 8 mm in diameter

    • f.

      Distance between the cuff and the corresponding arterial orifice less than 50 mm

    • g.

      The line between the cuff and the arterial orifice, as projected onto the vessel wall, deviates no more than 45 degrees from the long axis of the aorta.

  • 3.

    Access

    • a.

      Adequate iliac/femoral access compatible with a 22F (8.5-mm OD) delivery system

    • b.

      Brachial, axillary, or subclavian access vessel size compatible with the delivery profile of a 10F or 12F introducer sheath (3.3- or 4-mm OD).

Indications

  • Elective pararenal or thoracoabdominal aneurysms

  • Symptomatic or ruptured pararenal or thoracoabdominal aneurysms

Procedure

Case Presentation

A 72-year-old male patient presented with a 6.8-cm type V TAAA ( Fig. 12.2 ), based on the Crawford Classification modified by Safi and Miller. The patient had a previous myocardial infarction and coronary stent placement, chronic obstructive pulmonary disease (GOLD III), arterial hypertension, and diabetes mellitus type 2.

FIG. 12.2, A 6.8-cm thoracoabdominal aortic aneurysm extending from the distal thoracic aorta, including the celiac and superior mesenteric origins, but terminating proximal to the renal arteries.

Procedural Steps

Step 1. Anesthesia and approach

All patients undergo general anesthesia and a totally percutaneous approach using the Prostar XL 10F vascular closure device (Abbott Vascular, Redwood City, California, USA).

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