Fixing Bridge Technique Combining Distal Covered Self-Expandable With Proximal Balloon-Expandable Stent-Graft in Case of Branched Endografting

Objectives: The aim of the study was to describe the early and midterm results of the fixing bridge techniqueda combination of a distal covered self-expandable with proximal balloon expandable stent graftdduring branched thoracoabdominal aneurysm (TAAA) repair to limit the inci- dence of type IIIc endoleak (w2%). Methods: Between October 2016 and October 2021, all TAAAs undergo- ing fenestrated and branched endografting (fenestrated and branched endovascular aneurysm repair) with Cook (Cook Medical Inc, Blooming- ton, IN) and Jotec (Jotec, Hechingen, Germany) platforms were collected in a dedicated database. Visceral arteries features (length, diameter, orientation) were analyzed on the basis of preoperative computed to- mography scans using Aquarius software (TeraRecon, Inc, Durham, NC). In all cases, a self-expandable covered stent graft (Covera; BD Bard, Tempe, AZ; or Viabahn; W.L. Gore & Associates, Flagstaff, AZ) was used as bridge stent. In addition, proximal fixation using a balloon-expandable stent graft (E-ventus BX; Jotec) was performed. In six cases, the inferior mesenteric artery was preserved (using a parallel graft technique, iliac branch, or iliac leg released above the inferior mesenteric artery ostium). In nine cases, the TAAA was associated with obstructive disease of the iliac axis, and at least one hypogastric artery was preserved using an iliac branch (three cases) or a parallel graft technique (six cases). Follow-up was performed at 1 and 12 months with computed tomography and then annually. Aortic-related mortality, bridge stent occlusion, reinterven- tions, and branch instability were evaluated. Results: For a total of 60 TAAAs undergoing fenestrated and branched endovascular aneurysm repair, 215 visceral vessels were targeted. The average follow-up was 12 months. In three cases, an intraoperative bridge stent occlusion was registered. In two cases, the occlusion was resolved us- ing the Penumbra Indigo Aspiration System (Penumbra, Alameda, CA) and in one case using the AngioJet peripheral thrombectomy system (Boston Scientific, Marlborough, MA). At follow-up, aortic-related mortality was 0%, and freedom from branch instability and reintervention was 100%. Conclusions: In the case of complex aortic procedures, the combina- tion of a covered self-expandable stent graft proximally fixed with a covered balloon-expandable stent graft seems to be safe and feasible, with low rates of occlusion, reintervention, and branch instability at early and midterm follow-up. However, long-term follow-up is needed to assess the patency and instability of the bridge stents