Sandwich Endovascular Technique

The sandwich endovascular technique is an option for the total endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs). The technique consists of three major steps: (1) deployment of a thoracic stent-graft in a healthy, nonaneurysmal aortic segment of the thoracic aorta; (2) placement of long, self-expanding covered stents in the involved renovisceral vessels; and (3) deployment of abdominal tube endografts between the long, covered stents and the abdominal aorta. This creates the following configuration, from outer to inner side: thoracic device, self-expanding covered stents running from the aortic side branches to the proximal level of the thoracic device (chimney grafts) or to the distal abdominal aorta (periscopes), and lastly, abdominal tube endografts to cover the distal portion of the aneurysm in the abdominal aorta. The three “layers” of endovascular devices in the thoracoabdominal aorta (thoracic endograft > chimney or periscope grafts > abdominal tubes) create the term sandwich technique, or wrap technique.

Procedure

Case Presentation

The patient presented with a contained, ruptured aneurysm from a type Ia endoleak after fenestrated endovascular repair; originally performed in 2005 using a device with two fenestrations. In 2009 the patient underwent reintervention with placement of balloon-expandable covered stents in both renal arteries as a result of fracture of the right balloon-expandable bare-metal stent, which was primarily deployed. At this time the patient had an endoleak from the right renal artery, with significant expansion of the aneurysm sac. Seven years later, the patient presented with a contained rupture. Fig. 13.1 shows the new onset of type Ia endoleak based on computed tomography angiography (CTA).

The cause for the type Ia endoleak was fracture at the origin of the fenestrations ( Fig. 13.2 ).

Procedural Steps

1

Exposure of left axillary artery

The axillary artery was exposed through an incision in the deltopectoral groove. The pectoralis major muscle was divided in the direction of its fibers, as was the pectoralis minor muscle from its the insertion on the coracoid process.

2

Percutaneous transfemoral access

Percutaneous transfemoral access was achieved, using the Prostar XL device (Abbott) in a “preclose” technique. Stiff guidewires were advanced into the aorta, as in standard thoracic endovascular aortic repair (TEVAR).

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