Caudally directed in situ fenestrated endografting for emergent thoracoabdominal aortic aneurysm repair.

We previously described a transfemoral antegrade in situ laser fenestration technique (in situ fenestrated endovascular abdominal aortic aneurysm repair) for ruptured thoracoabdominal aortic aneurysms. In the present report, we have described an alternative technique of caudally directed in situ fenestrated endografts using upper extremity access for branch vessel incorporation. This technique involves partial deployment of the aortic stent graft in the thoracic aorta to achieve proximal control, followed by sequential branch incorporation using a laser probe through a steerable sheath, from the upper extremity access. The advantages of the technique include rapid proximal aortic control before branch incorporation without target vessel prestenting and separation of in situ fenestration from the target branch vessel origin, facilitating cannulation of angulated branch vessels.