Abstract
We have read with great interest the recent technical note of Nana et al 1 presenting an in situ fenestrated thoracic endovascular repair using for fenestration creation the Peripheral Go Back catheter (Bentley, Hechingen, Germany). They used a retrograde approach from left subclavian artery (LSA) to create the fenestration. We would like to comment on this interesting case by presenting a similar case in which an antegrade approach with a through guidewire from the femoral artery was used for a sub-acute type B aortic dissection (TBAD) after facing difficulties to accomplish the fenestration from LSA.
After the deployment of the thoracic endograft (Valiant, Medtronic, Santa Rosa, Calif) in zone 2, we used a steerable sheath (TourGuide Steerable Sheath, Medtronic, Santa Rosa, Calif) from the LSA to form its tip on a perpendicular view in the axis of the endograft. We used the Go Back catheter with success in introducing a 0.014 wire through the endograft to the ascending aorta. After dilatation of the in situ fenestration with a small-diameter coronary balloon, we exchanged to stiffer wire, but we were not able to introduce a cutting balloon to increase the size of the in situ fenestration. In several attempts from the LSA we pushed to introduce the materials through the in situ fenestration resulting in endograft contraction and contemporary losing its fixation to the outer aortic wall. As we mentioned, this was a sub-acute TBAD, and we were not in favor of any additional mechanical force in the proximal part of the endograft.
At this point, we exchanged again to a 0.014 wire, and we used the through-and-through technique snaring the guidewire from the right femoral artery. Thus, we managed to pass the cutting balloon from below without any difficulty as we pushed against the inside of the endograft and the aortic wall, having also a better angulation of the guidewire. (Figure 1A) Another important point is that with the change of the wire direction with the through-and-through technique, it was possible to overcome any contact with the nitinol springs of the graft such as in this case. After that, we concluded the case similarly to the Nana et al, but passing the bridging covered stent from below and having a nice final result (Figure 1B). We would like suggest that if there is any difficulty from LSA to create a fenestration with the Go Back catheter, a through-and-through technique from femoral artery should be considered.
(A) The creation of fenestration can be seen with the use of a balloon on a through and through wire. In final angiography, the fenestration can be seen along with patent the left vertebral artery. (B) The post-op computed tomography angiography shows patency and good formation of the in situ fenestration.
