The "safe-line" technique as theoretical additional attempt to mitigate spinal cord ischemia after urgent complete endovascular exclusion of a thoracoabdominal aortic aneurysm

Abstract

We describe the feasibility of a technique for temporary aneurysm sac reperfusion after endovascular single-stage thoracoabdominal aortic aneurysm exclusion, to be used in the case of postoperative spinal cord ischemia. Two cases were treated for impending rupture of a thoracoabdominal aortic aneurysm. Before completion of sac exclusion, a supplementary buddy wire (V-18 control guidewire; Boston Scientific) was advanced in parallel fashion from the left percutaneous femoral access into the aneurysmal sac on the posterior aspect of the endograft. Distal aneurysm exclusion was completed using the main superstiff guidewire, and the femoral access was closed with a percutaneous closure device (ProGlide; Abbott) in standard fashion, leaving in place the sole V-18 guidewire, draped in sterile fashion. In the case of spinal cord ischemia, the "safe-line" can be rapidly used for spinal reperfusion after trans-sealing exchange with a 6F, 65-cm-long Destination sheath (Terumo) connected to a 6F introducer on the contralateral femoral artery.

Keywords: Aortic aneurysm; Endovascular aneurysm repair; Paraplegia; Spinal cord ischemia; Thoracoabdominal.

Fig 1

Schematic drawings representing the “safe-line technique.” A, From left femoral artery access, before deployment of the distal aortic graft component, a 0.018-in. guidewire is advanced into the aneurysmal sac. B, Endovascular aneurysm exclusion completed via deployment of the distal aorto-bifurcated endograft from right femoral artery access, with the prepositioned 0.018-in. guidewire left in place. C, If postoperative spinal cord ischemia (SCI) occurs, the “safe line” is used to advance into the aneurysm sac, a 6F Destination sheath, which is then connected to the contralateral femoral artery access, allowing for quick sac reperfusion.

Fig 2

A, Computed tomography angiogram showing a thoracoabdominal aortic aneurysm (TAAA) with associated intramural hematoma. B, Postoperative computed tomography angiogram showing successful endovascular treatment with branched endovascular repair. C, Completion angiogram showing correct positioning of the endografts and bridging stents, with the V-18 guidewire (white arrow) left in the aneurysm sac, entering from the distal edge of the endograft. D-F, Percutaneous closure of left femoral artery access, with the V-18 guidewire left in place.

Fig 3

A, Computed tomography angiogram showing a thoracoabdominal aortic aneurysm (TAAA). B, Postoperative computed tomography angiogram showing successful TAAA treatment. C, Detail of left femoral artery access: a DrySeal introducer sheath is used to accommodate both the 0.035-in. superstiff guidewire used for deployment of the left limb and the V-18 guidewire used as a “safe line.” D and E, Intraoperative fluoroscopy showing the guidewire properly positioned behind the aortic main graft (arrows).

Fig 4

Detail of postoperative management of femoral artery access. After percutaneous closure, the V-18 guidewire is rolled-up (A) and draped in sterile fashion with a gentle compressive bandage applied (B).

Fig 5

Use of the “safe line” in the case of spinal cord ischemia (SCI). The guidewire is unwound (A), a 6F Destination introducer sheath is inserted directly into the aneurysm sac (B) and connected to the contralateral femoral percutaneous access via a three-way runner, reperfusing the aneurysmal sac (C). D, Intraoperative angiogram from the Destination sheath, confirming its correct position in the aneurysm sac (white arrow) with sac reperfusion.