Bifurcated In-Stent in Situ Technique for Creation of a Bifurcated Bridging Stent-Graft System to 2 Target Vessels Using a Single Directional Branch: A Report of 2 Cases.

OBJECTIVE

The objective of the study is to describe a novel bifurcated in-stent in situ technique (BIS2T) for creation of a bifurcated bridging stent-graft system to target 2 vessels using a single directional branch during complex endovascular aortic aneurysm.

TECHNIQUE: The technique uses 3 balloon-expandable stent-grafts. The first supporting stent-graft is deployed from the directional branch into the first target vessel or aneurysm sac. A reentry catheter is used to create an in situ fenestration in the first stent-graft, which is predilatated with a 3 mm 0.014 inch angioplasty balloon. This is exchanged for a 0.035 inch 5 Fr catheter and guidewire which is used for catheterization of the second target vessel via the in situ fenestration. The docking area of the first stent-graft is predilated. The second stent-graft is deployed into the second target with >1 cm overlap into the first stent-graft, followed by a matching third stent-graft in a kissing stent fashion to reinforce the bifurcation and achieve a "D shape" stent-graft configuration.

RESULTS

The BIS2T was used to treat 2 patients. Neither experienced complications or endoleaks, and both had patent branches on follow-up computed tomography angiography.

CONCLUSIONS

The BIS2T is a feasible option to incorporate 2 target vessels via a single directional branch.Clinical ImpactTarget vessel anatomy is a frequent limitation for successful endovascular incorporation using fenestrations or directional branches during complex endovascular aortic aneurysm repair. Numerous anatomical variations such as aberrant or accessory vessels, common celio-mesenteric trunks, or extension of the aneurysm/dissection into a target vessel may preclude successful incorporation using standard endovascular techniques. This technical note describes a novel bifurcated in-stent in situ technique (BIS2T) for the creation of a bifurcated bridging stent-graft system to target 2 vessels using a single directional branch. This approach may enable target vessel incorporation in challenging anatomical situations that might otherwise preclude endovascular treatment or require intentional artery coverage.