CTV03 - Repair of Thoracic Aortic Aneurysm Using Endovascular Transcaval Technique

Introduction/Purpose: Repair of thoracic aortic aneurysms (TAA) has evolved in recent history. Historically treated with open surgery, repair has largely shifted towards endovascular intervention. Thoracic endovascular aneurysm repair (TEVAR) has surpassed the open repair as the most common treatment for both TAA and type B dissection, accounting for 57.2% of aneurysm repairs and 50% of type B dissection repairs
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. It has been proven to have decreased early morbidity and mortality in comparison to the open approach
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. However, there are anatomical limitations to TEVAR. In patients with peripheral vascular disease or vessel tortuosity, it becomes dangerous to attempt percutaneous access or graft deployment for fear of severe complications
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. With the advancement of endovascular intervention, improvisations have been made to avoid complications associated with percutaneous access in these patients. One approach describes accessing the femoral vein and contralateral femoral artery and using a wire connected to electrocautery to cross from the inferior vena cava (IVC) into the aorta. This allows for the passing and deployment of the graft through an arteriotomy at a level of close approximation between the aorta and the inferior vena cava
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. This method has been described in transcatheter aortic valve replacements (TAVR)
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, however, there is a paucity of data using this technique in TEVAR. We describe an alternative approach to TEVAR for the patient with difficult peripheral vascular access by percutaneously accessing the aorta through the inferior vena cava.

Methods or Case Description:
A transcaval crossing point was chosen at the closest distance between the IVC and the aorta at L3-L4. An Astato wire inside of a cook 2x30 balloon inside of a 0.035 CXI catheter was utilized for transcaval crossing. Astato wire was connected to bovie using 50 watts. The electrocauterized wire was passed from the IVC into the aorta and snared using a 20 mm gooseneck snare that was passed into the aorta from the left groin (Figure d). 2.0 cook balloon was inflated to facilitate the passage of the CXI catheter across the newly created fistula. A Lunderquist wire was then passed through the cavoaortiic tract into the proximal descending aorta. 24-french GORE DrySeal sheath was passed without difficulty from the left femoral vein into the aorta (Figure e).

At this time a lunderquist wire was passed into the aorta from the right groin access site. A pigtail catheter was passed through the left groin access to the junction between the ascending aorta and aortic arch. An aortogram was preformed identifying all arch vessels. A 38x38x200 Medtronic © Valiant Captivia thoracic graft was passed through the right groin access into the aorta. It was deployed just distal to the left subclavian artery (Figure f). A 38x38x150 Medtronic © Valiant Captivia thoracic graft was deployed as an extension which covered the distal descending aortic ulcer extending just proximal to the celiac trunk (Figure g). At this time balloon angioplasty of the stent was completed and completion aortogram demonstrated no evidence of endoleak.

Outcomes: Patient tolerated the procedure well and no endoleaks were visualized at the end of the case. Follow up CT demonstrated the thoracic graft in the appropriate location without evidence of migration, endoleak, or enlarged aneurysmal sac.

Conclusion: In patients with significant peripheral vascular disease, a transcaval TEVAR is a reasonable and safe approach to repairing a thoracic aortic aneurysm.