A technical review of bail-out procedures to place Najuta stent-graft into the ascending aorta

Raffaella Berchiolli; Nicola Troisi; Giulia Bertagna; Andrea Colli; Laura Besola; Roberto Silingardi; Gioele Simonte; Giacomo Isernia; Italian Najuta registry collaborators

doi:10.1186/s42155-023-00351-4

A technical review of bail-out procedures to place Najuta stent-graft into the ascending aorta

CVIR Endovasc. 2023 Feb 21;6(1):7. doi: 10.1186/s42155-023-00351-4.

Authors

Raffaella Berchiolli^#¹, Nicola Troisi^#², Giulia Bertagna¹, Andrea Colli³, Laura Besola³, Roberto Silingardi⁴, Gioele Simonte⁵, Giacomo Isernia⁵; Italian Najuta registry collaborators

Collaborators

Affiliations

¹ Vascular Surgery Unit, Department of Translational Research and of New Technologies in Medicine and Surgery, University of Pisa, Cisanello Hospital, Via Roma 67, 56126, Pisa, Italy.
² Vascular Surgery Unit, Department of Translational Research and of New Technologies in Medicine and Surgery, University of Pisa, Cisanello Hospital, Via Roma 67, 56126, Pisa, Italy. nicola.troisi@unipi.it.
³ Division of Cardiac Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy.
⁴ Department of Vascular Surgery, University of Modena and Reggio Emilia, Nuovo Ospedale S. Agostino Estense, Modena, Italy.
⁵ Department of Vascular and Endovascular Surgery, University Hospital of Perugia, Perugia, Italy.

^# Contributed equally.

Abstract

Background: The Najuta stent-graft (Kawasumi Laboratories Inc., Tokyo, Japan) is usually easily advanced to the correct deployment position in the ascending aorta thanks to the pre-curved delivery J-sheath with all fenestrations automatically oriented towards the supra-aortic vessels. Aortic arch anatomy and delivery system stiffness could however represent limitations for proper endograft advancement, especially when the aortic arch bends sharply. The aim of this technical note is to report a series of bail-out procedures that could be useful to overcome the difficulties encountered during the Najuta stent-graft advancement up to the ascending aorta.

Main body: The insertion, positioning and deployment of a Najuta stent-graft requires a through-and-through guidewire technique using a .035″ 400 cm hydrophilic nitinol guidewire (Radifocus™ Guidewire M Non-Vascular, Terumo Corporation, Tokyo, Japan) with right brachial and both femoral accesses. When standard maneuver to put the endograft tip into the aortic arch, some bail-out procedures can be applied to obtain proper positioning. Five techniques are described into the text: positioning of a coaxial extra-stiff guidewire; positioning of a long introducer sheath down to the aortic root from the right brachial access; inflation of a balloon inside the ostia of the supra-aortic vessels; inflation of a balloon inside the aortic arch (coaxial to the device); and transapical access technique. This is a troubleshooting guide for allowing physicians to overcome various difficulties with the Najuta endograft as well as for other similar devices.

Short conclusion: Technical issues in advancing the delivery system of Najuta stent-graft could occur. Therefore, the rescue procedures described in this technical note could be useful to guarantee the correct positioning and deployment of the stent-graft.

Keywords: Aortic arch; Najuta stent-graft; Thoracic endovascular aortic repair (TEVAR).