Techniques for large sheath insertion during endovascular thoracic aortic aneurysm repair

Balloon angioplasty of the external iliac artery is performed via a femoral arteriotomy.

A ringed stripper is passed through the arteriotomy to further define the dissection plane.

The dissected atheromatous plaque, including the intima and inner media, is removed with a clamp.

Upon completion of the stent graft procedure residual disease within the common iliac artery is treated with a stent and the arteriotomy is closed.

Incision placement for retroperitoneal exposure of the common iliac artery or distal aorta. Only the surface of the access vessel needs to be exposed.

Placement of a double pursestring suture in the access vessel. Each of the concentric purse strings is constructed of 4-0 polytetrafluoroethylene-impregnated polyester suture for native vessels and 2-0 polypropylene sutures for Dacron graft initiated on opposite sides of the vessel and held by rubber tourniquets. The artery is punctured in the center of the purse string and a guidewire is inserted and manipulated into the proximal aorta.

Sheath placement. The sheath with its tapered dilator is placed over the stiff wire and fluoroscopically guided into the common iliac artery or aorta. The tourniquets can be used to control any puncture site bleeding around the sheath. All further exchanges occur through the sheath with its hemostatic valve. Sheath removal is accomplished with simultaneous traction on both purse-string sutures to relieve tension on the puncture and maintain hemostasis while the sutures are sequentially tied.

Avulsed external iliac artery after deployment of the endovascular stent graft.