Avoiding Aortic Valve Passage in Branched Arch Repair by Use of the Modified Balloon Nose Cone Technique.

Abstract

Purpose: To demonstrate the Modified Balloon Nose Cone Technique to avoid passage of the aortic valve in endovascular branched arch repair.

Technique: The technique is demonstrated in a 54-year-old patient after previous open repair of the ascending aorta and mechanical aortic valve replacement due to type A aortic dissection. The delivery system of a custom-made stent-graft with 3 inner branches was modified by subtotally sawing off its nose cone. Using a right transaxillary access, a sheath was introduced over a through-and-through (TAT) wire exiting the left groin and meeting the branched stent-graft in a rendezvous fashion. A balloon was used to bridge the gap between both sheaths. Passing the innominate artery, both sheaths were pushed into the ascending aorta to establish a loop configuration of the balloon until the correct landing zone was reached. The main body was deployed, and the supra-aortic target vessels were connected. After the procedure, the mechanical aortic valve showed unimpaired function.

Conclusion: The Modified Balloon Nose Cone Technique broadens the technical armamentarium in endovascular aortic arch repair offering a feasible solution to overcome the need of aortic valve passage. Especially patients with mechanical aortic valve could benefit from this method.

Clinical impact: To describe the feasibility and safety of the Modified Balloon Nose Cone Technique in a severely comorbid patient with residual Type A aortic dissection and history of ascending aortic repair and mechanical replacement of the aortic valve to broaden the technical armamentarium in endovascular aortic arch repair offering a feasible solution to overcome the need of aortic valve passage.