Reverse Cheese-Wire Septotomy to Create a Distal Landing Zone for Thoracic Endovascular Aortic Repair

Abstract

Purpose: The objective of this study is to describe a novel method for creating a distal landing zone for thoracic endovascular aortic repair (TEVAR) in chronic aortic dissection. The technique is described in a patient with prior total arch and descending aortic replacement, with false lumen expansion. Technique: A cheese-wire endovascular septotomy was desired to create a single lumen above the celiac axis. To avoid dividing the septum caudally across the visceral segment, we performed a modified septotomy in a cephalad direction. Stiff wires were passed into the prior surgical graft, through true lumen on the right and false lumen on the left. An additional wire was passed across an existing fenestration at the level of the celiac axis, and snared and externalized. 7F Ansel sheaths were advanced and positioned tip-to-tip at the fenestration. Using the stiff wires as tracks, the through-wire was pushed cephalad to endovascularly cut the septum. Angiogram demonstrated successful septotomy, and TEVAR was performed to just above the celiac with successful aneurysm exclusion and no endoleak or retrograde false lumen perfusion. Follow-up computed tomography angiogram (CTA) showed continued exclusion without false lumen perfusion. Conclusions: This novel modification in a reverse direction provides an alternative method for endovascular septotomy, when traditional septotomy may threaten the visceral vessels.

Early results of transcatheter electrosurgical aortic septotomy for endovascular repair of chronic dissecting aortoiliac aneurysms

“…These include laser fenestration using a focused energized tip and the cheese wire septotomy technique using a V-shaped wire with manual traction to divide the dissection flap. 4 , 5 TEAS uses a polygonal wire configuration, which still focuses most of the energy at the septum, but also allows for a slightly wider concentration of energy. This theoretically addresses the thickening of the septum and associated clot seen in chronic dissecting aortoiliac aneurysms without allowing for alternative current paths to cause collateral damage to surrounding tissue.…”

“…In chronic dissection, endovascular repair remains challenging given the septum rigidity, compression of the true lumen (TL), and target vessels arising from the false lumen. Existing techniques, such as cheese wire fenestration, 4 , 5 balloon dissection flap fracture, 6 and focused laser fenestration, 7 aim to either obliterate the false lumen or create a common aortic lumen, which will allow for improved endovascular aortic repair (EVAR) device proximal and distal seals and visceral branch perfusion. 8 …”

Cutting balloon septotomy for repair of right common iliac artery aneurysm in the setting of type B aortic dissection

“… 4 The reverse “cheese wire” technique has been described in several reports to avoid some of these complications in the visceral segments of the aorta. 7 , 8 This technique uses the “cheese wire” method of using a wire in a sawing technique to divide the intimal flap, but the wire is advanced in a cephalad direction to avoid dividing the septum in the visceral segment. 7 A later study reported using electrocautery to heat the wire to cut the intimal septum under IVUS and fluoroscopic guidance.…”

“… 7 , 8 This technique uses the “cheese wire” method of using a wire in a sawing technique to divide the intimal flap, but the wire is advanced in a cephalad direction to avoid dividing the septum in the visceral segment. 7 A later study reported using electrocautery to heat the wire to cut the intimal septum under IVUS and fluoroscopic guidance. 9 Kabbani et al 9 described a more controlled and precise septotomy compared with the traditional cheese wire fenestration technique because it allows for real-time monitoring of the wire position and less pulling of the wire itself.…”