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Rodrigues et al. Vessel Plus 2024;8:10 https://dx.doi.org/10.20517/2574-1209.2023.109 Page 7 of 15

Figure 3. The Cook Zenith t-Branch graft is an off-thelf model designed with four downgoing directional cuffs for the celiac axis (CA),
superior mesenteric artery (SMA), and both renal arteries (A); Three-dimensional reconstruction of a computed tomographic
angiography of a patient with a Type III thoracoabdominal aortic aneurysm treated with a T-Branch stent graft with repair extended to
the common iliac arteries bilaterally (B). All branches are bridged with self-expanding covered stents (Viabahn or Fluency) and typically
reinforced with a bare-metal stent in its entirety (C). (Reproduced by permission of Mayo Foundation for Medical Educationand
Research. All rights reserved).

Bridging stents
The selection of an appropriate bridging stent for F/B-EVAR is largely influenced by the design of the main
aortic component . Fenestrated designs usually employ a balloon-expandable stent to secure the target
[39]
vessel in alignment and subsequently flare it to reduce the risk of component separation. On the other hand,
directional branches can be paired with either balloon-expandable or self-expanding stents owing to
offering adequate length for overlap, providing a sufficient seal to prevent endoleaks or component
separation . The balloon-expandable covered stents currently in use in the United States include iCAST
[47]
(Atrium Medical, Hudson, NH) or VBX (W. L. Gore & Associates, Flagstaff, AZ), and the self-expanding
covered stents used are Viabahn (W. L. Gore & Associates, Flagstaff, AZ) or Fluency (Bard Peripheral
Vascular, Tempe, AZ), whereas European centers have access to the Bentley Be-Graft and Be-Graft plus
(Bentley InnoMed GmbH, Hechingen) with encouraging results .
[47]

Directional branches incorporated using balloon-expandable stents have demonstrated lower freedom from
target artery instability, endoleak, and secondary intervention compared to self-expandable stent and hybrid
stent-graft configuration (a proximal balloon-expandable stent with a distal self-expanding stent)
[48]
[Figure 5].

Access vessel
The selection of vessels for access starts with the study of femoral and iliac vessels to assess for occlusive
disease, presence of calcification, diameter, and tortuosity. Currently, the development of novel steerable
sheaths has allowed the advancement of stents from a total femoral (TF) access, making this approach
preferable, providing relative comfort to the patient and technical ease. Upper extremity (UE) arterial access
via brachial or axillary artery may be chosen to favor catheterization of target vessels and allow the passage