Retrograde Approach for Antegrade Inner Branches in a Precannulated Off-the-Shelf Multibranch Device

Purpose: The purpose of this technical note was to describe the application of the combination of precannulated branches and a femoral approach for bridging stent graft deployment in branched endovascular aneurysm repair. Technique: The technique is shown in a 65-year-old woman treated for thoracoabdominal aneurysm type I with endovascular repair using a multibranched device. The stent graft is an off-the-shelf device with 4 precannulated inner branches. Access to the precannulated branches is gained using a steerable sheath from retrograde femoral access instead of using access via the upper extremities. For this purpose, a 0.018ʺ wire introduced to the precannulated tube is snared into the steerable sheath. Next, the steerable sheath is guided into a stable position inside the branch. With this technique, the implantation of this off-the-shelf multibranch device could be completed safe and quickly with a full femoral approach avoiding upper extremity access. Conclusion: The combination of a precannulated multibranch stent graft with a full femoral approach for target vessel revascularisation is a feasible and quick method for complex endovascular repair.

Ipsilateral Iliac Branch Repair Using a Looped Wire, Precannulated Gate Technique

Purpose To describe a novel, entirely ipsilateral femoral technique for distal endograft extension using the Gore Iliac Branch Endoprosthesis. Technique Femoral arterial access is obtained on the side of the intended repair, and a 16F sheath is inserted over a stiff wire. A looped wire is used to pre-cannulate the internal gate of the IBE device prior to insertion, and the device is then positioned and deployed. This through-wire guides access over the IBE flow divider and into the internal gate with a steerable sheath. The internal iliac artery is then selected, and a Viabahn VBX balloon-expandable stent (W.L. Gore, Flagstaff, AZ) is advanced into position and deployed. We present the successful completion of this technique in 4 patients. Conclusion This novel technique allows distal endograft extension with an IBE device using only ipsilateral femoral access and is particularly useful for patients with aneurysmal iliac degeneration in the setting of prior open or endovascular aneurysm repair. This eliminates the need for upper extremity access or contralateral femoral access and navigation across the steep flow divider.

A case report of pulmonary vein isolation with radiofrequency catheter using superior vena cava approach in patient with paroxysmal atrial fibrillation and inferior vena cava filter

Background Transseptal puncture and pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) are generally performed via the inferior vena cava (IVC). However, in cases where the IVC is inaccessible, a specific strategy may be needed. Case summary An 86-year-old woman with paroxysmal AF and an IVC filter in situ was referred to our hospital for ablation therapy. An IVC filter for pulmonary embolism and deep venous thrombosis had been implanted 15 years prior, therefore we selected a transoesophageal echocardiography (TOE)-guided transseptal puncture using a superior vena cava (SVC) approach. After the single transseptal puncture, we performed fast anatomical mapping, voltage mapping by multipolar mapping catheter, and then PVI by contact force-guided radiofrequency catheter using a steerable sheath. Following the ablation, bidirectional conduction block between the four pulmonary veins and the left atrium was confirmed by both radiofrequency and mapping catheter. No complications occurred and no recurrence of AF was documented in the 12 months after the procedure. Discussion When performing a transseptal puncture during AF ablation, an SVC approach, via access through the right internal jugular vein, enables the sheath to directly approach the left atrium without angulation and improves operability of the ablation catheter. Combining the use of general anaesthesia, TOE, a steerable sheath, and contact force-guided ablation may contribute to achieving minimally invasive PVI with a single transseptal puncture via an SVC approach.