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Transapical Through-and-Through Wire Technique: Another Addition to the Toolbox for Difficult Arch Anatomies

In this issue of JEVT, Ramponi and colleagues describe a novel approach to route a through-and-through wire to stabilize a thoracic endograft during deployment in challenging proximal aortic anatomy. The through-and-through wire technique is well known as an important adjunct in thoracic endovascular aortic repair (TEVAR) to enable endograft passage and to stabilize the device during deployment. This added assistance is especially important in patients with short proximal landing zones or tortuous aortic anatomy and for fenestrated and branched devices that require precise delivery. The authors expand this technique utilizing the left ventricular apex as an entry point for the ‘‘body-floss wire’’ by using a minithoracotomy. The wire is externalized at the femoral access site after passing through the aortic valve, aorta, and iliac arteries. Compared to the well-known technique of a transbrachiofemoral wire, this route offers the advantage of control and stabilization even in the proximal aortic arch and ascending aorta without interfering with the takeoff of the innominate artery, which may be sharp-angled and a source of embolization. Compared to the recently described transseptal through-wire technique, Ramponi’s transapical technique avoids the transseptal puncture and interference of the wire with the anterior mitral leaflet, which may lead to significant hemodynamic compromise when tension is put on the wire. Apart from these obvious advantages of Ramponi’s technique, the minithoracotomy and left ventricular sheath insertion add other sources of potential adverse events and a procedural step, which in most institutions requires multidisciplinary cooperation with cardiac surgeons experienced in this access technique. Multidisciplinary cooperation itself should, of course, be seen as an advantage and a requirement in the treatment of complex proximal aortic lesions. However, the transapical approach is high risk for major adverse cardiac and cerebrovascular events when used for transcatheter aortic valve implantation. The transapical route is another important component in the endovascular toolbox for challenging aortic interventions, and we can anticipate that more through-and-through routes will be reported, such as the transventricular-transseptal or the transseptal-transbrachial route. The selection of the through-wire technique in a specific case will depend not only on individual patient anatomy but also on collaboration among vascular surgeons, interventional cardiologists, and cardiac surgeons and the operator’s preference for a particular approach. The authors chose to use a number of stabilizing techniques in this challenging anatomy, such as rapid ventricular pacing, a tip-capture– secured endograft, and a through-and-through wire. Nevertheless, technical success was impaired by a retrograde type A dissection, another complication typical of TEVAR in proximal