We sincerely appreciate the insightful comments of Drs Ysa and Mikelarena on our paper “Endograft limb trimming and resheathing can be an alternative for emergent aortic repair without adequate stent graft availability.”1 Their interest and kind comments offer an excellent opportunity to further explain the technique applied and its potential limitations.
A word of caution has to precede any further details on our procedure as we strongly believe that tabletop modifications of commercially available endovascular devices are justifiable only in the context of emergent setups without a valid alternative. This being said, our department sports an experimental surgery program in anatomic and animal models hosted by the Centro Tecnológico de Formación of INIBIC (A Coruña Institute for Biomedical Research). The experience gained in this laboratory has enhanced our knowledge of the device's limits and behavior in a variety of uncommon situations, encouraging us to apply some slight device modifications in very particular clinical scenarios, as reported.1
Concerning Endurant iliac limbs (Medtronic, Fridley, Minn), we have been able to fully deploy and resheath them after inversion and compression with a stainless steel wire from a sternal suture (Ethicon, Somerville, NJ). We have also removed a variable number of stent graft sections without a full deployment on a sterile side table, holding within the delivery system the remaining portion to be implanted. This allows the arrangement of different covered cuffs of various diameters (up to 28 mm) and lengths (as short as 12 mm, with few if any clinical applications). For example, deploying and removing the first nine stents of a 16-28-124 iliac limb would allow a quick and easy preparation of a 28-28-30 mm cuff; in our experience, there are no specific limitations for the amount of graft that can be safely removed or any issues with the delivery system. For an enhanced management and preservation of the system's inner tube, partially deploying the iliac limb with a stiff guidewire inserted has been of help. Also, the use of a disposable sterile cautery (FIAB SpA, Florence, Italy) for neatening up the polyester fabric cutout can be considered if available.
We are grateful both for the keen comments and for getting the opportunity to clarify and revisit the technical details of our cases.
Reference
- 1.Álvarez Marcos F., Couto Mallón D., Vilariño López-Barranco P., Vilariño Rico J., Franco Meijide F.J., Caeiro Quinteiro S. Endograft trimming and resheathing can be an alternative for emergent aortic repair without adequate stent graft availability. J Vasc Surg Cases and Innovative Techniques. 2016;3:88–91. doi: 10.1016/j.jvscit.2016.04.003. [DOI] [PMC free article] [PubMed] [Google Scholar]