Up-and-Over Snare Technique for the Difficult Contralateral Gate Access

The use of two- and three-piece modular aortic stent grafts requires proper catheterization of the contralateral gate. This step can be readily accomplished with appropriate pre- and intraprocedural planning. In some cases, catheterization can be challenging. This chapter describes a bailout technique when the conventional use of a catheter and wire fails or is unlikely to succeed within a timely interval. An Amplatz Gooseneck snare (ev3 Endovascular Inc., Plymouth, MN) or EN Snare (Merit Medical Systems Inc. South Jordan, UT) may be employed to grasp a Glidewire (Terumo Medical Corp., Somerset, NJ) that is threaded through a reverse curve catheter (e.g., Sos 1/2) over the bifurcation and brought below the contralateral gate. In so doing, cannulation of the contralateral gate is readily achieved.