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International Society For Minimally Invasive Cardiothoracic Surgery

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Conceptualization And Prototyping Of A Stent-based Endovascular Approach To Generate Large-bore Vascular Access To Central Thoracic Vessels
Janina Emunds1, Felix Vorwold1, Dana Rizk1, Koray Durak1, Sebastian Kalverkamp1, Flutura Hima1, Lasse Strudthoff2, Ulrich Steinseifer2, Valentine Gesché3, Jan Spillner1.
1Department of Thoracic and Cardiovascular surgery, RWTH Aachen University Hospital, Aachen, Germany, 2Department of Cardiovascular Engineering, Helmholtz-Institute for Biomedical Engineering, Aachen, Germany, 3PerAGraft GmbH, Aachen, Germany.

BACKGROUND: Generation of large-bore central vascular anastomosis for different purposes is still a surgical domain. We investigated an endovascular approach to generate this anastomosis by an "inside-out" approach. METHODS: Two different approaches were conceptualized. Both consisted of an endovascular stent graft prosthesis with an end-to-side connected side-graft. In the first so-called "elephant trunk technique" the side-arm was located inside the main graft and subsequently developed to the outside in analogy of the "elephant trunk technique". In a second so-called "simultaneous approach" the side-arm was located on the outside of the main graft. With the deployment of the device the side-arm was developed to the outside. Prototypes of these approaches were handcrafted from commercially available endoprosthesis, vascular prosthesis, nitinol wires and self-developed introducer sheathes. Both approaches were investigated in a test bench and in cadaveric specimen from the slaughterhouse. The work process was recorded and evaluated. RESULTS: The elephant trunk technique used a thread, which was connected to the distant end of the side-arm to retrieve it from the inside to the outside of the main graft. Thus, the side-arm reached out of the punctured vessel. The simultaneous approach used a tight-fitting additional sheath around the side-arm. This sheath carried the side-arm through the vascular wall simultaneously during deployment. For both approaches a perforation through the vascular wall was necessary and feasible by puncture and electrocautery without significant vascular damage via an 8 mm introducer sheath. The subsequent deployment was proved successful regarding expansion of the whole combined stent graft. Both approaches allowed continuous blood flow during deployment process. In both approaches the (closed) side-arm could be retrieved using a minimally invasive approach. CONCLUSIONS: A principal feasibility of our new minimally invasive inside-out approach could be approved in-vitro. This endovascular approach to generate a large bore vascular anastomosis may allow an application in aortic and thoracic assist device surgery. Further investigations of this approach are necessary and ongoing. This work is part of the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG) project Nr. 347325614.

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