Crossing the mesh of multilayer stents to treat ostial stenosis in aortic side branches

Concerns exist whether the mesh of previously implanted multilayer stents can be crossed with existing interventional devices to treat endovascularly de novo stenotic lesions in covered aortic side branches. We describe the endovascular procedures used to treat three symptomatic patients (two male, one female; mean age: 69 years) who had undergone treatment for thoracoabdominal aortic aneurysms with multilayer stents a mean of 40 months earlier. The procedure involved six general steps: 1) using a brachial approach to navigate a 6 Fr Judkins Right guiding catheter close to the target branch ostium; 2) crossing the stent’s mesh covering the targeted side-branch ostium with a high-torque soft-tip guidewire; 3) advancing a low-profile, semicompliant 2-mm coronary balloon across the mesh and dilating it; 4) exchanging the 2-mm for a 3- or 4-mm noncompliant coronary balloon, and applying the balloon anchor technique to advance the guiding catheter across the mesh to engage it in the branch artery; 5) treating the stenotic lesion with balloon predilatation; and 6) implanting a low-profile, high-radial force stent through the mesh with the side branch stent protruding into the aorta. All target lesions were successfully treated without complications and patent at six-month follow-up. This case series demonstrates that the mesh of previously implanted multilayer stents can be crossed safely with readily available interventional devices using the balloon anchor technique. Endovascular treatment of multilayer stent-covered visceral and renal arteries is possible without the need for open surgery. These findings should be validated in larger studies with longer follow-up.