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Endostaples for Distal Fixation in a Thoracic Endovascular Aortic Aneurysm Repair (TEVAR)
Ratna C Medicherla, Evan Lipsitz
Montefiore Medical Center, Bronx, NY

BACKGROUND: We report a case of 77-year-old woman with an asymptomatic enlarging distal thoracic aortic aneurysm (TAA) treated with endovascular repair using endostaples.
METHODS: The patient was a former smoker with a history of hypertension, chronic kidney disease, asthma, and hypothyroidism. Physical examination was significant for a pulsatile mass in the mid abdomen. She was followed with serial computed tomographic angiography (CTA) for five years. The TAA measured 3.8cm in 2009 enlarging to 5.5cm in 2013. CTA revealed a short distal neck of approximately 5mm proximal to the celiac axis. Therefore, the decision was made to use endostaples for distal fixation.
RESULTS: After informed consent, the patient was taken to the operating room. A 7-French sheath was inserted via a right femoral exposure. Left common femoral artery was accessed percutaneously. An aortogram confirmed a short distal neck. The celiac artery was selected with a guidewire, and access was maintained in the hepatic artery with a glide catheter. A COOK Zenith TX2® 28mm x 80mm Endo Graft (Cook Medical, Bloomington, Ind) was deployed. Four Aptus Heli-FX Thoracic EndoAnchors (Aptus Endosystems Inc, Sunnyvale, CA) were placed at 2, 4, 8, 10 o’clock. A completion angiogram showed no endoleak and good filling of the celiac artery. The patient tolerated the procedure well without any complications. She was discharged the next day, and remains well at two month follow-up. Two month follow up CTA confirmed good placement of graft with no endoleak and aneurysm completely excluded.
CONCLUSIONS: There are multiple options for obtaining distal fixation during TEVAR. These include coverage of the celiac axis, barbs/hooks on the graft, distal graft visceral uncovered bare metal stents, fenestrated/scalloped stent grafts, branched endografts, parallel stenting (chimney, snorkel, or periscope), and endoanchors/endostaples/endoscrews. This case is an example of a distal TAA with difficult anatomy due to a short distal neck treated with endovascular repair using endostaples to ensure distal fixation and reduce the risk of migration. Endostaples can serve as a safe and viable alternative that is minimally invasive for handling short landing zones. Early results with endostaples are promising, but further studies are warranted to evaluate long-term safety and durability. The ANCHOR registry is designed to evaluate patients from multiple sites treated with the Aptus Heli-FX EndoAnchor System and is currently enrolling.

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