Right Anterior Oblique-Based Approach for Managing Wire Wrap During Fenestrated TEVAR

Abstract

Purpose:

To describe a standardized technique for managing “wire wrap” during the implantation of fenestrated endografts in the aortic arch. This approach aims to enhance wire position predictability, reduce unnecessary device manipulations, and improve procedural safety in fenestrated thoracic endovascular aortic repair (f-TEVAR).

Technique:

The technique is illustrated through 3 representative cases, including a customized triple-wide scallop endograft with a single fenestration featuring a preloaded guidewire, as well as 2 additional physician-modified endograft cases. The procedure begins with detailed preoperative imaging to plan graft selection and positioning. A through-and-through wire system is employed, with careful advancement of the delivery system into the descending thoracic aorta. We distinguish 3 possible scenarios in right anterior oblique fluoroscopy regarding wire position: guidewire aligned, graft positioned posterior to the wire, or graft positioned anterior to the wire. Specific rotational maneuvers—clockwise or counterclockwise—are performed in the descending thoracic aorta to resolve wire wrapping. Once corrected, the fenestration aligns precisely with the targeted supra-aortic branch for graft deployment.

Conclusion:

The systematic approach to addressing “wire wrap” during f-TEVAR minimizes embolization and device distortion risks while optimizing procedural efficiency. This reproducible technique provides a valuable tool for advancing endovascular repair in challenging aortic arch pathologies.

Clinical Impact

This standardized technique for managing “wire wrap” during fenestrated thoracic endovascular aortic repair provides a reproducible and practical approach to a well-recognized intraoperative challenge. By systematizing wire handling, the technique enhances procedural safety and minimizes unplanned maneuvers that may increase operative time and radiation exposure while also facilitating device alignment and deployment in demanding scenarios. The innovation lies in offering a simple, easily adoptable strategy that can be consistently applied across operators and centers, supporting safer dissemination of complex endovascular techniques and promoting more predictable outcomes in advanced aortic repair.