The TRIP technique: A trilumen catheter-assisted contralateral gate precannulation method for distal bifurcated component during thoracoabdominal branched endovascular repair

Contralateral gate cannulation of the distal bifurcated component during thoracoabdominal branched endovascular repair can be challenging in patients with previous endovascular aneurysm repair (EVAR) because multiple indwelling and newly implanted stent graft components may crowd the distal aortic field and obscure wire behavior. We describe a trilumen catheter-assisted contralateral gate precannulation (TRIP) technique for distal bifurcated component during thoracoabdominal branched endovascular repair. A 81-year-old man presented 7 years after infrarenal EVAR with a type IA endoleak from a previous suprarenal fixation stent graft. Because of his operative risk, off the shelf endovascular thoracoabdominal branched endovascular repair was selected. After establishment of through-and-through access, placement of the aortic component, and completion of visceral branch stenting, attention was turned to distal bifurcated component deployment using the TRIP technique. Before deployment of the distal bifurcated component, a trilumen catheter was advanced from the upper-extremity sheath to the ipsilateral femoral sheath over the existing through-and-through wire. A 0.014-inch wire was introduced through the trilumen catheter and passed through the removable guidewire tube of the distal bifurcated component to precannulate the contralateral gate. After deployment of the distal bifurcated component, a 7F, 75-cm-long sheath was advanced over the precannulated wire through the contralateral gate. A 0.035-inch buddy wire was then introduced, snared from the contralateral femoral access, and exchanged to establish secure through-and-through access for contralateral limb delivery. The TRIP technique enabled confident contralateral gate access despite a crowded distal aortic configuration and may be useful during thoracoabdominal branched endovascular repair for type IA endoleak after previous EVAR when conventional gate cannulation is expected to be difficult.