Use of steerable sheaths for complex aortic procedures

Abstract

Objectives: To demonstrate the ease with which steerable sheaths, designed for cardiac electrophysiological applications, can be used to aid endovascular treatment of a wide range of non-cardiac vascular disease and to assist with target vessel cannulation in branched and fenestrated aortic grafts.

Methods: A retrospective medical chart review was carried out to identify cases from a single vascular surgery unit (2019-2022) where the HeartSpan Steerable Sheath (HSS) (Merit Medical, South Jordan, UT, USA) was utilised to enable endovascular management of complex vascular pathology. A case presentation of branch graft insertion performed entirely via distal access is described and used to help identify pertinent sheath characteristics and technical considerations, and to illustrate the advantages and disadvantages of the design for modified use in target vessel cannulation.

Results: The HSS was used in the endovascular treatment of different vascular pathologies in 15 patients (23 target vessels) where access to the vessels using standard catheters and approaches was not possible. Cannulation and subsequent stenting were successful for 21 of the 23 target vessels in total. Of these cases, the HSS was used as an adjunct for deployment of fenestrated endovascular graft systems when conventional techniques for canulation of target vessels had failed on five occasions. On another four occasions, the HSS enabled full deployment of the entire Zenith® t-Branch™ Thoracoabdominal Endovascular Graft system from an exclusively femoral approach. An additional three cases involved use of the HSS for superior mesenteric artery cannulation in patients with mesenteric ischaemia. The device was also used once in each of the following cases: contralateral common iliac cannulation, cannulation of contralateral internal iliac artery for coil embolisation, and access of a contralateral iliac branched device. There were no stent dislocations and all aortic branches that were patent at the completion of each case remained so 1-year post procedure.

Conclusion: Steerable sheaths designed for cardiac electrophysical applications, like the HSS Introducer, can be successfully utilised for cannulation of challenging target vessels in a wide range of aortic endovascular procedures. This modified approach may salvage cases that would otherwise be considered inoperable in regions of the world where steerable sheaths designed for aortic use are not readily available.

Keywords: Endovascular aortic repair; branched endovascular aortic repair; cannulation; steerable catheter.

Figure 1.

Stages of deployment of bridging stents into visceral target vessels during branched-graft deployment. (a) and (b) left renal artery cannulation. (c) right renal artery cannulation. (d) right renal angiogram. (e) superior mesenteric artery stent deployment. (f) left renal stent deployment. In all images the HeartSpan has been flexed to 180°.

Figure 2.

Cannulation procedure. (a) cannulation and stenting of critical stenosis of coeliac artery. (b) cannulation of renal fenestration. (c) accessing internal iliac artery in patient with complex arteriovenous abnormality. (d) example of poor filling of aorta during angiography via the steerable sheath.