Gap Steering (GPS) Technique: An Adjunct for Challenging Renovisceral Branch Cannulation in Total Transfemoral Fenestrated Endovascular Aortic Repair

The GPS technique is a feasible adjunct for difficult cannulations in F-EVAR using PMEGs. It avoids additional devices and is particularly suited for total transfemoral repair using currently available steerable sheaths.Clinical ImpactDifficult renovisceral target vessel cannulation remains a major limitation to achieving total transfemoral F-EVAR using physician-modified endografts (PMEGs). This challenge often necessitates upper-extremity access or complex adjunctive maneuvers, increasing procedural invasiveness and access-related risks. The Gap Steering (GPS) technique offers a practical adjunctive strategy using a commercially available steerable sheath to achieve controlled directional guidewire manipulation at the fenestration-aortic wall interface. It enables selective cannulation without additional access routes, larger delivery systems, or device modification. This reproducible and fully transfemoral approach has the potential to improve procedural efficiency and expand the applicability of PMEG-based F-EVAR in complex aortic repair.