The treatment of aneurysms that affect the exit of arterial branches requires the use of techniques such as ChEVAR or FEVAR. The most critical and complex aspect of this procedure lies in achieving a correct alignment of the tractions with their respective target arteries. As these are prostheses designed to suit the patient, urgent intervention can not be addressed. In this way, the use of endografts modified by the surgeon himself (PMEG) is becoming popular. The use of aortic models manufactured in 3D printers can provide benefit to adjust the location of fenestrations. Therefore, it would be appropriate to develop a method that reduces the difficulty of these procedures, facilitating the correct orientation of the fenestrations and minimizing the risks and complications of the procedure, making it safer, faster and more effective. We describe a new technique that achieves these objectives by means of a system of preloaded guides on the fenestrations practiced in the endoprostheses.

We describe the technique for cannulation of an arterial bifurcation through an endoprosthesis fenestrated in situ. The entire procedure is performed coaxially through a single access point. We describe the technique in a series of steps that, in summary, consist of performing a through&through maneuver (Ilustration 1), achieving tension in the guidewires with a balloon catheter inserted into the destination artery. The guidewires are preloaded into the endograft through the fenestration and modified in the form of a slipknot (Ilustration 2). We simplify the description of the procedure for a single fenestration (although conceptually it could be extended to the number of fenestrations that were necessary).

At the moment, we have only been able to test the technique in anatomical models. The technique allows that, even if the fenestrations are slightly misaligned with the target vessel, the interlocking guide system has already gained the target vessel prior to prosthesis deployment. This technique not only limits its use to cannulation of visceral arteries but could also be used to cannulate vessels of the aortic arch, hypogastric arteries and, in general, any area of arterial bifurcation.

We describe a resource technique for urgent cases that require the use of modified prostheses with fenestrations. This would simply be the conceptualization of a technique. The next step would be to transfer this model to the industry to refine the procedure carrying it out in a safer way and even standardize the procedure with off-the-shelf devices that do not require manipulation by the surgeon himself.

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