Modified DrySeal Sheath U-turn Technique with Sheath Escalation and a Triple Coaxial System for Complex Gore Excluder Iliac Branch Endoprosthesis Placement: A Retrospective Cohort
- 1Department of Cardiovascular Surgery, Sendai City Hospital, Sendai, Japan
Abstract
Objective: Standard Gore Excluder Iliac Branch Endoprosthesis (IBE) placement precedes endovascular aortic repair (EVAR) main body deployment. This sequence is unavailable after previous EVAR and may be unsuitable with short common iliac arteries or a limited renal to internal iliac artery (IIA) distance. The original ipsilateral U-turn technique enables post main body IBE placement by redirecting a 12 F sheath towards the IIA through the same femoral access. Limited working space within the sheath and wire device interaction may impede delivery. This paper describes two modifications intended to address these delivery limitations: U-turn sheath escalation to ≥ 14 F (modification 1) and a 20/16/12 F triple coaxial sheath system (TCSS). Procedural feasibility and early outcomes for the original and modified U-turn techniques are reported.
Methods: Consecutive limbs treated at one centre with the original or modified U-turn technique between December 2023 and December 2025 were reviewed retrospectively; outcomes were summarised descriptively.
Results: The technique was used in 46 limbs of 34 patients: 37 during initial EVAR and nine after previous EVAR. The original 12 F technique, modification 1, and TCSS were used in 15, 18, and 13 limbs, respectively. Technical success was achieved in all limbs. Computed tomography within one month showed no type I or III endoleak; one bridging stent graft occluded in the TCSS group. There were no pelvic ischaemic complications or external iliac artery dissections or perforations. Three percutaneous closure failures required suture repair.
Conclusion: The U-turn approach enabled post-main body IBE placement in selected patients. When access and U-turn space were adequate, the U-turn sheath was generally escalated to ≥ 14 F; the original 12 F configuration was retained when either was limited, and TCSS was reserved for bridging expected to benefit from pathway separation or distal support. These off label strategies require careful planning. Prospective multicentre studies should assess reproducibility, comparative safety, and durability.
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BibTeX
@article{tajima2026modified,
title = {{Modified DrySeal Sheath U-turn Technique with Sheath Escalation and a Triple Coaxial System for Complex Gore Excluder Iliac Branch Endoprosthesis Placement: A Retrospective Cohort}},
author = {Yuta Tajima and Yoshihisa Tamate and Ai Ishizawa and Tetsuo Watanabe},
journal = {EJVES Vascular Forum},
year = {2026},
month = sep,
doi = {10.1016/j.ejvsvf.2026.09.002},
url = {https://doi.org/10.1016/j.ejvsvf.2026.09.002},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Modified DrySeal Sheath U-turn Technique with Sheath Escalation and a Triple Coaxial System for Complex Gore Excluder Iliac Branch Endoprosthesis Placement: A Retrospective Cohort
AU - Yuta Tajima
AU - Yoshihisa Tamate
AU - Ai Ishizawa
AU - Tetsuo Watanabe
PY - 2026
DA - 2026/09/23
JO - EJVES Vascular Forum
DO - 10.1016/j.ejvsvf.2026.09.002
UR - https://doi.org/10.1016/j.ejvsvf.2026.09.002
AB - Objective: Standard Gore Excluder Iliac Branch Endoprosthesis (IBE) placement precedes endovascular aortic repair (EVAR) main body deployment. This sequence is unavailable after previous EVAR and may be unsuitable with short common iliac arteries or a limited renal to internal iliac artery (IIA) distance. The original ipsilateral U-turn technique enables post main body IBE placement by redirecting a 12 F sheath towards the IIA through the same femoral access. Limited working space within the sheath and wire device interaction may impede delivery. This paper describes two modifications intended to address these delivery limitations: U-turn sheath escalation to ≥ 14 F (modification 1) and a 20/16/12 F triple coaxial sheath system (TCSS). Procedural feasibility and early outcomes for the original and modified U-turn techniques are reported. Methods: Consecutive limbs treated at one centre with the original or modified U-turn technique between December 2023 and December 2025 were reviewed retrospectively; outcomes were summarised descriptively. Results: The technique was used in 46 limbs of 34 patients: 37 during initial EVAR and nine after previous EVAR. The original 12 F technique, modification 1, and TCSS were used in 15, 18, and 13 limbs, respectively. Technical success was achieved in all limbs. Computed tomography within one month showed no type I or III endoleak; one bridging stent graft occluded in the TCSS group. There were no pelvic ischaemic complications or external iliac artery dissections or perforations. Three percutaneous closure failures required suture repair. Conclusion: The U-turn approach enabled post-main body IBE placement in selected patients. When access and U-turn space were adequate, the U-turn sheath was generally escalated to ≥ 14 F; the original 12 F configuration was retained when either was limited, and TCSS was reserved for bridging expected to benefit from pathway separation or distal support. These off label strategies require careful planning. Prospective multicentre studies should assess reproducibility, comparative safety, and durability.
SN - 2666-688X
ER -