Modified Snare-Ride Technique for Target Vessel Stenting in FB-EVAR

The field of endovascular surgery continues to evolve rapidly with the introduction of novel techniques and devices. Among the most significant advances in recent decades is the development of branched and fenestrated endografts, which have become the cornerstone of treatment for complex aortic pathologies, including thoracoabdominal aortic aneurysms. These devices enable the preservation of visceral vessel perfusion while allowing for effective aneurysm exclusion. However, their use introduces technical challenges that demand a high level of expertise, particularly during the catheterization of target vessels. Target vessel cannulation is widely recognized as one of the most technically demanding and time-consuming steps in fenestrated and branched endovascular aneurysm repair (FEVAR and BEVAR, respectively). This difficulty is often exacerbated in patients with hostile anatomy – such as extreme aortic angulation, severe vessel tortuosity, small-caliber, or heavily calcified arteries. In such settings, prolonged attempts at vessel catheterization may increase the risk of complications, including ischemic injury to abdominal organs, dissection, perforation, or embolization due to plaque disruption. To address these procedural challenges, several bailout strategies have been introduced. These techniques are generally reserved for non-standard cases and are not employed in routine or straightforward anatomies. One such strategy is the snare-ride technique, which has gained recognition as a practical and reproducible approach using widely available endovascular tools. It involves the snaring of a guidewire from the aortic component and advancing the wire and the snare assembly into the target vessel, using femoral access. While effective, this technique has raised concerns about its potential to cause endothelial trauma, particularly when the snare is advanced into a diseased vessel. To mitigate these risks, we propose modifying the traditional snare-ride technique. In this article, we introduce the Modified Snare-Ride Technique , a bailout approach designed to enhance the safety and effectiveness of target vessel cannulation in anatomically complex settings. After obtaining access to the intended target vessel with a stiff supporting wire, large sheath, and a deflecting sheath for control, through-and-through access is obtained from the portal to the contralateral stiff sheath. Once established, the lower stiff sheath is advanced to the origin of the target vessel, thereby pinning the through-and-through wire in position near the target vessel orifice. In doing so, the portal sheath can then be advanced along the through-and-through wire to the vessel origin for easy cannulation and delivery of the bridging stent. The modification avoids advancing the entire snare system into the vessel and instead uses a through-and-through access to improve pushability, control, and deliverability. This adjustment minimizes mechanical damage to the vessel wall and reduces the risk of vascular injury. However, its usability is dependent upon device and sheath size compatibility. By enhancing wire support and control with deflectable sheaths, this modified strategy provides an alternative that can be selectively employed when traditional techniques fail or are unsafe.