Great vessel transposition for antegrade delivery of the TAG endoprosthesis in the proximal aortic arch

Purpose: To report a technique for antegrade delivery of the TAG stent-graft during repair of lesions in the proximal aortic arch. Technique: Via an 8-cm median sternotomy, a bifurcated graft, usually 14 or 16 mm in diameter, is anastomosed to the ascending aorta with 4-0 Prolene suture; a 10-mm straight graft is cut obliquely and anastomosed to the heel of the bifurcated graft for delivery of the endograft antegrade across the aortic arch. The great vessels in turn are clamped, transected at the arch, and sutured to the bypass graft. A 9-F sheath is secured in the conduit, and a 250-cm angled hydrophilic guidewire is passed to the desired iliac artery and exteriorized through the femoral sheath. The conduit is clamped, and the TAG's delivery sheath is substituted for the 9-F sheath. A marker is placed on the conduit to assure that the stent-graft is deployed just beyond the limb origins of the bifurcated graft. The conduit is introduced across the aortic arch, followed by the endograft, which is positioned at the marker as the sheath is withdrawn into the conduit. After completion angiography, the delivery sheath is removed, and the conduit is transected and oversewn. Heparinization is reversed, and the incision is closed, with one mediastinal drainage tube in place. Conclusions: This technique allows precise delivery of the endoluminal graft at the proximal aortic arch, thus avoiding problems with retrograde delivery.