Lift Sandwich Grafting Enables Transfemoral Abdominal Aortic Branch Incorporation during Endovascular Aortic Repair for Chronic Type B Aortic Dissection

Abstract

Chronic type B aortic dissections with continued aneurysmal expansion of the thoracoabdominal aorta after the initial thoracic endovascular aortic repair represent a subset of aortic pathology in which staged distal extension to seal additional septal tears can be advantageous. This approach may require incorporation of visceral or renal branches into the distal seal zone, while maintaining the possibility of further distal extension in the future. We describe a novel technique for incorporation of the celiac axis, with a branch stent graft delivered from a transfemoral approach, then lifted cranially to create an antegrade sandwich graft configuration in a 59-year-old male who presented with a complicated type B aortic dissection requiring coverage of the celiac artery. Utilizing the previous thoracic endograft as a platform for sandwich grafting, a self-expanding stent graft was deployed into the celiac artery from a femoral approach. A steerable sheath with an anchoring balloon was used to lift the stent into an up-facing snorkel position, which was subsequently sandwiched with another thoracic stent graft terminating proximal to the superior mesenteric artery. When single visceral or renal branch incorporation is desired, sandwich grafting via a "lift" technique limits the extent of aortic coverage and reduces the number of branch components, without increasing the complexity of additional visceral and renal branch incorporation during future endovascular aortic repair.