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Purpose: The purpose was to demonstrate a new arch endograft configuration to allow total endovascular aortic arch repair exclusive from transfemoral approach., Technique: The custom-made multi-branched arch endograft (Cook Medical, Bloomington, Indiana) features 3 inner branches (IBs) for supra-aortic vessels incorporation and complete endovascular arch repair. Traditionally, the innominate and left carotid branches are anterograde IBs, requiring upper access for incorporation of these vessels, and the left subclavian branch is an upward-facing IB that can be incorporated from transfemoral access. We report a novel device configuration with only upward-facing IBs, allowing exclusive transfemoral route for total endovascular arch repair. Technical aspects, implantation technique, and limitations are described thoroughly., Conclusion: Herein is described an arch endograft configuration that simplifies endovascular aortic arch repair, allowing supra-aortic vessel incorporation through a transfemoral route only. This innovative design may serve as another alternative in selected patients., Clinical Impact: This innovative endograft design, with only upward-facing inner branches, simplifies the total endovascular aortic arch repair by allowing for a exclusively transfemoral approach. This may reduce procedural complexity and minimizes risks associated with multiple access points. It provides another alternative, particularly beneficial for selected high-risk patients for open repair, potentially expanding the applicability of endovascular treatments for aortic arch pathologies., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MF is a proctor for Cook Medical. The other authors have no conflicts of interest.

Purpose: To demonstrate the technical aspects of the novel Penumbra Indigo Lightning Flash System (Penumbra, Inc.) for mechanical thrombectomy of pulmonary embolism (PE)., Technique: The novel Penumbra Lightning Flash catheter is a 16 French (F) sheath-compatible device designed for advanced thrombectomy, especially in the pulmonary arteries. This device has large thrombus burden removal capacity; however, technical nuances are necessary to accomplish more with efficacy pulmonary embolism management. Access sites, pulmonary arteries catheterization technique, thrombectomy device navigation and mechanism of action are described thoroughly., Conclusion: Penumbra Indigo Lightning Flash system for mechanical thrombectomy as other catheter-directed treatments (CDTs) represents a major advance in contemporary PE management. With favorable safety profile and efficacy, CDTs have become an integral component of the multidisciplinary approach to PE care., Clinical Impact: The article highlights the Penumbra Indigo Lightning Flash System as a significant advancement in mechanical thrombectomy for pulmonary embolism (PE). By detailing technical aspects and procedural nuances, it supports clinicians for improvement in endovascular PE management. The system's integration into multidisciplinary care represents a major step forward, providing an effective alternative to traditional therapies, particularly for high-risk PE patients. This innovation promises to enhance patient outcomes in contemporary PE management., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: TC is a speaker for Penumbra, Inc. The other authors have no conflicts of interest.

Purpose: To demonstrate the feasibility of the modification to preserve intercostal arteries of the t-Branch Endograft (Cook Medical, Bloomington, IN) in an urgent setting, associated with a less invasive approach for branch incorporation from percutaneous femoral access with steerable sheaths., Technique: A 73-year-old female patient presented at our institution with intense abdominal pain. Angiotomography showed a 50-mm juxtarenal aortic aneurysm, with no signs of rupture. Urgent endovascular repair was indicated due to abdominal symptom with an off-the-shelf multi-branched endograft. To limit descending thoracic aortic coverage, we performed t-Branch modification to preserve intercostal arteries and minimize the risk of spinal cord injury, associated with a percutaneous transfemoral approach and branch incorporation with steerable sheaths to avoid the risks associated with a superior axillary or brachial access. Control angiotomography showed adequate aneurysm sac exclusion with patency of all four visceral vessels., Conclusion: t-Branch-modified endograft to limit aortic coverage is an alternative option in urgent cases to diminish the risk of spinal cord injury, and association of steerable sheaths with branch incorporation is leading complex aortic repairs to an even less invasive procedure., Clinical Impact: This paper highlights the possibility of performing complex endovascular aortic repair in an urgent setting with modification of an off-the-shelf multi branched endograft limiting intercostal arteries coverage, thereby diminishing the risk of spinal cord ischemia. This technical innovation provides an alternative for clinicians when treating large, rapidly expanding, or symptomatic juxtarenal, pararenal, paravisceral or type 4 thoracoabdominal aortic aneurysms that could not wait for a custom-made device and do not need extensive thoracic aortic coverage that an off-the-shelf device provides. In summary, expand the possibilities of an endovascular repair of complex aortic aneurysms.

Purpose: To demonstrate an alternative access to perform directional branch catheterization during complex endovascular aortic repair., Technique: Urgent endovascular aortic repair was indicated to treat a symptomatic post dissection thoracoabdominal aneurysm with large infrarenal dilatation with an off-the-shelf t-Branch endograft (Cook Medical, Bloomington, IN, USA). Traditional proximal arterial accesses were not suitable due to a previous aortic arch endograft. A novel approach was performed through a left postero-lateral thoracotomy, isolation of the descending thoracic aorta and anastomosed a polyester graft conduit to allow sheaths passage to the thoracoabdominal aorta with subsequently directional branch catheterization., Conclusion: The descending thoracic aortic conduit technique is an effective alternative for directional branch catheterization and should be considered whenever traditional proximal arterial accesses are not suitable and other endografts configurations not considered due to anatomic limitations.

Purpose: To demonstrate an off-the-shelf multibranched (t-Branch) modification to allow intercostal arteries preservation during juxtarenal, pararenal, paravisceral, and extent IV thoracoabdominal aortic aneurysm repair. Technique: The t-Branch is an off-the-shelf device not customized for specific patient anatomy and may be offered for urgent endovascular repair for patients with complex aortic aneurysms. However, a concern when treating patients who do not aneurysms extending above the celiac axis is that the more proximal extension which is required with this device may render patients at high risk for spinal cord injury. We report a novel technique with t-Branch modification performing a 180° fabric back windows at the first 2 sealing stents that allow perfusion to the intercostal arteries. Conclusion: T-Branch-PIA (preserving intercostal arteries) modification limits intercostal arteries coverage while optimizing proximal seal zone in juxtarenal, pararenal, paravisceral, and extent IV thoracoabdominal aneurysms, thereby may decrease the risk of spinal cord injury.