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Three new techniques for creation of a steerable sheath, a 4F snare, and bidirectional sheath inversion using existing endovascular materials  Alexandros.

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Presentation on theme: "Three new techniques for creation of a steerable sheath, a 4F snare, and bidirectional sheath inversion using existing endovascular materials  Alexandros."— Presentation transcript:

1 Three new techniques for creation of a steerable sheath, a 4F snare, and bidirectional sheath inversion using existing endovascular materials  Alexandros Mallios, MD, Willy Yankovic, MD, Benoit Boura, MD, Myriam Combes, MD  Journal of Vascular Surgery  Volume 56, Issue 3, Pages e3 (September 2012) DOI: /j.jvs Copyright © 2012 Society for Vascular Surgery Terms and Conditions

2 Fig 1 A-C, A guidewire (yellow arrow) is passed through a flexible sheath (red arrow), folded back on itself, and introduced into a nonflexible wider sheath (light blue arrow). The steerable element may exit the nonflexible sheath at the required level for use. D, Pulling the wire (purple arrow) that returns back to us achieves the desired angulation. Rotating the larger nonflexible sheath also rotates the guiding system (circular arrow). A vertebral catheter with a cannulating wire can be inserted into the flexible sheath to cannulate the target vessel (green arrow). Journal of Vascular Surgery  , e3DOI: ( /j.jvs ) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

3 Fig 2 A strong support for cannulation of very angulated vessels can be achieved. A, Simulation of a very angulated renal or superior mesenteric artery. B, Testing the steerable sheath for cannulation of fenestrations. Without support from our system, the wire is folding because it is not stable enough to support the passage of the sheath. C and D, Creating the steerable system for cannulation of fenestrations: the nonflexible sheath supports the internal flexible sheath that guides the cannulating wire (black arrow, nonflexible sheath; blue arrow, flexible steering sheath; yellow arrow, cannulating sheath; red arrow, pulling wire that is steering the sheath). By rotating the external nonflexible sheath (light blue arrow), we can rotate the entire system very reliably. E, By pulling the wire of our custom-made steerable sheath and rotating toward the target vessel, cannulation was immediate with a simple Terumo wire. Journal of Vascular Surgery  , e3DOI: ( /j.jvs ) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

4 Fig 3 Creation of the snare. From left to right: Insertion of a inch Terumo wire into the 4F catheter (straight–stiff tip first). After it exits from the other side of the catheter, we reinsert it to create the loop. The size can be greatly modified. If we need to undo the snare at some point during the procedure, we can push one of the two sides of the wire and pull the other (red and yellow arrows). Journal of Vascular Surgery  , e3DOI: ( /j.jvs ) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

5 Fig 4 A and B, We introduce the custom-made snare at the desired level with the use of a 4F sheath. C and D, By pushing only one of the two wires (arrow), we give the desired wide shape that reaches the size of an aneurysm. Journal of Vascular Surgery  , e3DOI: ( /j.jvs ) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

6 Fig 5 A and B, Pulling both wires back will close the loop and capture the desired material. C-E, The device was also tested for assistance in cannulation of fenestrations. The custom-made lasso is advanced parallel in the same sheath and is used to “hold down” the wire. Pulling and releasing the loop while slowly advancing the sheath will finally guide it into the fenestration. Journal of Vascular Surgery  , e3DOI: ( /j.jvs ) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

7 Fig 6 A, Puncture of the Vanchie 3 at the level of angulation in line with the long axis; then, at this hole, we introduce the inch wire in retrograde direction (the stiff part of the guidewire). B and C, Introduction of the 5F Vanchie 3 catheter into the sheath. D, Arrival of the catheter with slight withdrawal of the sheath. Note that the inch wire is not exiting from the normal tip of the catheter. A 360° rotation of the Vanchie catheter is possible at this position. E, Introduction of a second inch wire within the catheter. F, Wire in both directions. Journal of Vascular Surgery  , e3DOI: ( /j.jvs ) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

8 Appendix Fig 1 (online only)
A, Pulling the wire (red straight arrow) that returns back to us achieves the desired angulation. Rotating the larger nonflexible sheath also rotates the guiding system (circular arrow). B, A vertebral catheter with a cannulating wire can be inserted into the flexible sheath to cannulate the target vessel (yellow arrow). Journal of Vascular Surgery  , e3DOI: ( /j.jvs ) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

9 Appendix Fig 2 (online only)
In parallel with the first wire, and within the flexible sheath, a 4F vertebral catheter and second cannulating wire can be advanced toward the target vessel, here the contralateral iliac artery. Journal of Vascular Surgery  , e3DOI: ( /j.jvs ) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

10 Appendix Fig 3 (online only)
A and B, Various degrees of angulation can be achieved. C, Contralateral limb of stent graft. D, No-touch technique for the renal artery. E, Simulation of a very angulated renal or superior mesenteric artery. Journal of Vascular Surgery  , e3DOI: ( /j.jvs ) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

11 Appendix Fig 4 (online only)
A Zenith TX2 graft, fenestrated on the bench was used for the tests. We have used only one transverse marker below the fenestration with length equal to the fenestration. We believe that this is equally effective but has the advantage of less-radiopaque elements compared with the current practice of four markers per fenestration that gives quite a “congested” image, which is tiring and confusing for the operator, especially in long procedures. Journal of Vascular Surgery  , e3DOI: ( /j.jvs ) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

12 Appendix Fig 5 (online only)
By pulling the wire of our custom-made steerable sheath and rotating toward the target vessel, cannulation was immediate with a simple Terumo wire. Journal of Vascular Surgery  , e3DOI: ( /j.jvs ) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

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