Knife fighting lies

There are many so-called “experts” who claim to be able to teach you either knife fighting or defense against a knife. The problem is that most of them are just teaching regurgitated martial arts, usually from the Philippines. While I have lots of respect for the martial arts of other lands, the truth is that you live where you do. Odds are you are not in a “knife culture.” And that means that whatever you do regarding knives must:

A) Work to keep you alive against how you are likely to be attacked by a knife in your homeland
B) If it does work, not put you in prison for murder or manslaughter

While B is important, it only becomes an issue if you survive A. Unfortunately, based on a lot of what I have been seeing taught with my own eyes or encountered while working with the students of these self-proclaimed “knife experts” getting past A is going to be a whole lot tougher than you think. Quite simply, most knife assaults are assassination attempts…how they occur is significantly different than how one “knife fights.” While I express my opinions on other knife instructors elsewhere, what this page is for is to help you avoid some of the more common pitfalls with what is being taught out there.

Oh yeah, one more thing, always remember…it’s your ass on the line out there, so don’t let *anybody* tell you that you don’t have the right to ask about these things or think for yourself.

Lie #1 You’re going to have time to draw your own weapon
In all the times I have been assaulted with knives, only once was I able to pull my own weapon. And I didn’t carry a folder, I carried a sheath knife that I had repeatedly practiced speed drawing. I could, in a crisis, draw and deploy a knife in just over one second. This is not idle boasting, I demonstrate it in many of my videos. And yet, despite this incredible rate of speed, when attacked I didn’t have time to draw my knife except for the one time that I leaped wildly backwards to gain space.

That’s because by the time I realized there was a knife involved, I was already being attacked.

Not long ago I was involved in a discussion about a young biker who had been blown off his barstool by a shotgun blast. What had disturbed me is that he had been involved in an altercation in the bar earlier and had not withdrawn, thereby signing his death warrant. However, an Australian bouncer rightfully commented that the ages between 18 and 24 is where these kinds of lifesaving  lessons tend to be learned — and those who don’t learn them, or aren’t lucky, never get any older. It is only the young and inexperienced who make certain kinds of mistakes.

Most knife “fighting” training is predicated on the assumption that you have somehow managed to get a blade in your hand. Quite honestly, if you you are attacked by either a young punk, a total incompetent  or someone who was brandishing the knife in order to get you to back off then there is a chance that you might have time to draw you own weapon.

However, if you are dealing with anyone with any experience, street savvy or cunning, you will not be able to draw your own blade when you are attacked.  Against such a person, there is just not enough time. He won’t show his weapon  before he attacks. That’s because those who are foolish enough to brandish weapons  in places where weapons are common don’t live long themselves.

And yet that is exactly what you are expecting him to do so you can draw your own knife and defeat him.

Lie #2 It’s going to be a knife “fight”
Shortly before his death, I was sitting at the NRA convention in Phoenix with Col. Rex Applegate, the father of American military knife work. We were discussing the fad of  “knife fighting” that we, as old timers in the subject, were both amused and bemused with. He summed up the problem with what was being promoted as knife work as “They’re teaching dueling.” By this he meant standing there toe-to-toe, with the same weapons and trying to kill each other like civilized gentlemen.

Not to be the bearer of bad tidings, but the reason someone uses a weapon on another human being is to stack the deck in their favor. People don’t use weapons to fight, they use weapons to win. The absolute last thing any attacker wants to do is to fight you with equal weapons. If he was looking for a fight he wouldn’t have attacked you with a weapon in the first place. And if he knows you have a knife, he is going to attack you with a bigger and better weapon to keep you from winning.

Personally one of the things that I really respect the Dog Brothers for doing is experimenting with mismatched weapon contests. *That* is a reality. You pull a knife and he gets a club. You pull a club and he pulls a gun. There is no fighting involved, you use the superior weapon to disable your opponent. And you do it before he does it to you.

As far as your attacker is concerned this is not a fight, it is an assassination. He is not going to want to stand there with you and hack it out. Unfortunately, this is exactly the fantasy that many so-called knife fighting instructors promote. The absolute last thing you want to do is to try to “fight.”

Another reason that you need to chase the idea of “knife fighting” out of your head is that in many states there is this attitude that “consensual fights” are best resolved by throwing both of the morons who participated  in jail. It is true, you have the right to defend yourself against attack, but if you decide to fight someone, it isn’t self-defense anymore, and if you use a lethal weapon on someone in a “knife fight” that you could have avoided, then you have yourself a gang of problems ahead of you. That is unless you like being gang raped in a prison shower


Lie #3 “But what if I’m cornered?”
Common sense tells us that knife fighting is dangerous. And yet, like a dog circling a bear’s den — where a smarter part of it knows not to wake that sleeping bear,  yet another, more instinctive part is urging it on  — many people who train in knife fight have the same torn desires. One of the biggest issues goading these people is Do they have what it takes?”.

Unlike dogs, however, human beings have the ability for self-deception and rationalization. And one of the ways that we human fool ourselves is that we fantasize about situations where we would be able to give ourselves permission to find out if we “have  it.”   Such people strongly resist the idea that knife fighting is a bad place to go. It is literally as though they are seeking to find an excuse.

One of the strongest indicator of this fantasy mindset is the reaction when they are told to flee instead of fighting with a knife, literally the next words out of their mouths will be “But what if I am cornered and can’t run?” There are many such similar excuses that they can use and they all start with the word but: “but what if I am with old people or children and can’t run?”, “But what if I am out of shape (or infirm) and can’t run?” In all cases, of the millions of possible options  available they always seem to focus on the one that requires them to engage in a knife fight.

The truth is, it is incredibly difficult to “corner” someone who is determined to leave. Basically because he will use your face as traction or squirt through the smallest of holes. However, if the person’s desire not to engage in physical violence is stronger than his desire to leave, it is very easy to corner someone. If you ask any experienced  LEO, corrections officer or mental ward orderly which they would rather face, a person who wants to fight them, or someone who will climb over them to escape, to a man they will tell you the former. They know the latter will hurt them more and be harder to defeat. That’s because that person is fully committed to a course of action. Whereas a person who has allowed themselves to be “cornered” will still be of a divided heart and therefore not able to fight at full capacity. And that is exactly what it will take in order to survive such a “no win” situation that they have put themselves into.

That is the true danger of this kind of thinking. Because part of you does want to know if you have what it takes and “can do it,” you can unconsciously trick yourself into not taking appropriate precautions and ignoring danger signals. Your pride and ego will blind you about what you are doing until it is too late. Once there however, your life — if it continues past that moment — will be utterly destroyed.

Don’t fantasize about being in a situation where you have to use your knife fighting skills, because you can end up tricking yourself into just such a situation by blinding yourself to possible escape routes.

Lie #4 He’s going to attack you a certain way
I have a demonstration that I do during knife seminars. I find the highest ranking Filipino martial arts player present and I tell him to check and pass my attack. I then proceed to do a well balanced, fast, cautious attack. This is a legitimate and fast attack, and they tend to block it. I then tell them to block the another attack – and aiming for the same target – I do a prison yard rush on them. To this day I have gutted everyone of them.

The reason? They are entirely different knife attacks.

Many years ago Don Pentacost wrote a book called Put ’em down, take ’em out: Knife fighting from Folsom Prison. In it Don pointed out how actual knife homicides occurred in maximum security prisons. Putting it mildly, he outraged countless martial artists by what he said in that book, who to this day still disparage the book. Except for one thing, that prison yard rush is exactly what I use to gut so many of them. It is not a sophisticated attack, but it is a very common way to attack someone with a knife in the USA.

The FMA are predicated on one basic assumption, that you will be fighting a trained knifer. The problem with that assumption is that not everyone attacks the way that someone trained in the FMA will attack you. This is problematic because the counters of the FMA are designed to work against how people with FMA training will attack you. Against these kinds of attacks, the counters work great.

The bottom line is, in the Western culture, someone who is attacking you with a knife is attempting to murder you. They are not going to be hanging back cautiously in fear of your weapon and your fighting skill. Instead they will usually attempt to overwhelm you and quickly kill you by whatever means necessary. Such an attack is totally different than the well balanced and liquid attacks of the FMA. And that is totally different than how someone from Italy will attack you with a knife. And that is different than how someone from Venezuela is going to attack with a knife. And that is different than how someone from Brazil will attack you with a knife. And that is different than how someone from South Africa is going to attack you with a knife. And that is totally different than how someone from China will attack you with a knife. I know because I have traveled around the world and encountered knife fighting systems from all of those places.

I know that those who are selling knife fighting training and others who haven’t seen these other systems will deny it, but: Just because you know how to handle one, doesn’t mean you know how to handle the others. Each are different, and each are equally lethal. And those differences CAN kill you.

Lie# 5 And then he is going to passively stand there while you carve him
Just like in the magazines and in the training drills.

What few people realize is that a wild defensive flailing while holding a knife, is just as dangerous and damaging as an intentional strike. In fact, it is often more dangerous because of its unpredictable nature. If you are indeed tearing someone up, his defensive moves can hurt you badly — especially if he is flailing around trying to stop your next attack.

I have seen a serious over emphasis on defense before closing and a serious lack of emphasis after closing —  either one will get you mauled, if not killed.

BTW, this is over and above the fact that he might not be willing to let you carve him and he might do something different after his initial attack fails…like attack again in a different manner. Or if his first one did succeed to attack again.

Fights are never static…and his ability to move is his ability to hurt you…and do it before you have a chance to do your really cool moves.

Lie #6 Trapping and stripping
Defanging the snake is something that is commonly taught at higher levels. Subtle and complex moves are drilled into the advanced students so they can either knock the knife out of their attacker’s hands or carve the knife out of his hand


There’s just one problem with it, you have a snowball’s chance in hell of making it work. The truth is these are what we call “green moves.” They have very little to do with actual knife defense and very much to do with keeping  the student involved in the system and paying money (which in the U.S. is green, ergo the term green move). Such moves rely on the attacker moving “just so” and thereby putting you in the perfect position to do the move.

The thing is even the older masters tell you that these moves are purely opportunity and chance. And yet, these moves are often over-emphasized at the expense of more effective altercation ending moves. In short, they train in elements as though they were the most important element or the highest degree of the art. Call me silly, but I feel that getting out alive is the best proof of skill, not how many subtle and complex moves you know.

In truth, unless an attacker is drunk or pathetically slow the odds of successfully catching his hand and doing all these marvelous joint locks or controlling moves are very, very slim. Furthermore you are not going to be able to effectively control a wildly struggling opponent’s arm with only one hand. Odds are that he will be able to wiggle free of it and cause you some degree of damage.

This does, however, bring up an issue that I made a passing reference to previously. I often see too much of an emphasis placed on controlling your opponent so you can safely close. The raw reality is that you cannot effectively control someone out at such a distance. While there are things that you can do that will give you momentary advantage, it is nowhere complete control. Unfortunately, I have seen too many people try to establish control so they can enter safely. It has been my experience, that you cannot do this. What you can do is create an opening, enter and then prevent him from countering. But if you attempt to hang back until it is “safe” to enter, then you will take more damage staying back trying to create the perfect solution.

On top of the already  unpleasant realities, there is something else that is far more important. Okay, so it’s only important if you *don’t* like taking showers with lots of guys with tattoos. Once you disarm an opponent whether by leverage or your own blade, if you continue to use the knife on him, that isn’t self-defense anymore. At the very least it is attempted murder, probably manslaughter and —  if your lawyer isn’t very good — you can possibly go down for murder if the DA is having a particularly bad hair day.

Lie #7 Bio-mechanical cutting
Technically this should not be on this page at all: First because I respect Bram Frank, and secondly — as far as it goes — it is a sound concept.  The simple fact is that cutting tendons, muscles and nerves does work. A slash will destroy/hinder motor abilities. There is no argument about it’s effectiveness.

However, like Jeff Cooper’s well-thought out and considered “Better to be judged by twelve than carried by six” was bastardized  by Bubbas and “gun nuts” into a clich?of ignorance of the legal issues, I have seen this idea seriously misinterpreted and bandied about by those ignorant of the laws, precedents and legal nuances regarding use of lethal force. Much of the discussion about using a knife to  inflict this kind of wound is the same fantasy thinking as when a toothless redneck, after being called upon his statement of “ah’d jes shoot ‘im,” responds with the Cooperism. Neither of them are taking into account that the law has a slightly different outlook about their use of a lethal force weapon on another human being.

In the eyes of the law, a knife is a deadly weapon. It’s use on another human is  classified as lethal force. And the only time you are justified in using lethal force — in most states — is when you are “in  immediate threat of death or grievous bodily injury.” In otherwords, if it is bad enough where you have to use a knife on someone, it is bad enough to kill them. If you are at a point where you are just trying to wound someone, you are not in enough danger to justify using a knife.

This is the ghost of the old “shooting him in the leg” misconception so many people had. People would shoot an intruder and then tell the police that they were only trying to wound him. This left them open to all kinds of criminal charges and civil litigation — from the person they had shot. There is a natural hesitation to take another human life. However, when this manifests in seeking to “wound” someone in order to make them “go away” you end up in a very dangerous legal grey area. And the fact that you were even in a situation where a knife was used is going to make that grey area more dangerous. Remember, a knife is considered a thug’s weapon.

Lie #8 Knowing how to stickfight means you know how to knife fight
I have a friend Randy  Brannan who is a physicist. The man is basically brilliant and when he starts talking physics, I shut up, sit down and listen, because he knows what he is talking about. Thing is Randy and I used to fight with broadswords at the California Renaissance Faire. These live-steel bouts were not only unchoreographed, but were basically wild brawls (it helps to understand that at the time, we were both young and often slightly drunk  — conditions known to produce “it seemed like a good idea at the time” thinking). Later Randy would go out and study Kali/Escrima. Having experience using a far wider range of weapons than many of his fellow kali students gave him a slightly different perspective. One day while discussing this very subject he said:

People claim that a stick is an average weapon. That it has similarities to all weapons. This is true, it does. But then they claim that if you know how to use a stick you can use all weapons. This is not true. What they don’t understand is that the differences are just as important as the similarities.

Give that man a cigar…although I might tweak his last sentence to read “what they don’t want to understand.” Just because you are proficient with one type of tool doesn’t automatically mean you can translate that skill to another weapon. And yet a great many people tell themselves that this is the case, in fact, they rather emphatically insist is it so. Apparently the appeal of being a “master of all weapons” is greater than being proficient with just a stick.

The simple truth is that different weapons handle differently. The have different weights, different sizes, different timing, different requirements and different uses. There are indeed certain similarities, but unless you want to end up kneeling in a dark parking lot trying to hold your guts in, you had better stop telling yourself about the similarities and start looking at the differences.

To begin with a stick doesn’t have an edge. With blade work the point and the edge are critical components, but not necessarily so with sticks. Edge control is pretty much the indicator between someone who knows how to use a knife and a stick jock trying to tell you that he knows knife work. If you know what to look for you can spot the difference with just one move — even if it is a fast one. In fact, the faster the move, the more obvious it is.

The physics of a stick do not require this exactness of edge control. This is because a stick is an impact weapon, were as a blade is designed to cut, slice, stab and sometimes, hack. If you do not have your edge on target, then you create a totally different set of physics and reactions other than the one you want.

If you are learning stick fighting then accept that you are learning stick fighting, that is a legitimate pursuit. If you are learning knife work, then you are learning knife work…while there are similarities there are radical differences. Don’t tell yourself or allow yourself to be told different. If you don’t believe me, try working out with a wide variety of weapons and do the exact same move. These differences especially become manifest when your weapon encounters flesh.

Lie # 9 Knowing kali makes you a knife fighter
Kali, Escrima, Arnis, FMA, all of them have the aura and mystery of being weapons based arts. Deadly, savage arts of the Filipino warriors. Lurid stories about guerrilla actions against Japanese invaders, duels and death matches that the founder of the style was involved in abound.

Quite honestly what these maestros survived is incredible and is more than worthy of kudos. These older gentlemen survived a totally different culture, socio-economic environment, time and, in some cases, a World War and foreign invasion of their homeland.

That having been said however, just because the founder of the system or lineage was a walking piece of bad-assed real-estate doesn’t make you one.

They weren’t knife fighters, those people were survivors. It’s what comes from living a hellishly hard life. While they had physical skill that helped them, what kept them alive, what allowed them to strike fast enough, hard enough and brutally enough wasn’t their art — it was the commitment not to die. It was that grim savagery to do whatever is necessary and to do it faster and harder than the other person that kept them alive. In the lexicon, they had “heart.”

Their art just allowed them to do that faster.

Knowing an art doesn’t give you that kind of commitment, that kind of ruthlessness, that kind of grim endurance or that willingness to descend into savagery to stay alive. Just knowing the art doesn’t make you a knife fighter. You have to have “heart” as well — that willingness to wade through hell and come out the other side.

Lie #10 Grappling with a knife
I was in Germany with a group of martial artists teaching “street knife work.” While demonstrating an empty-handed with one of them, he tackled me and took me to the ground (This is no big deal as when I do demo’s I don’t allow “courtesy attacks.” I insist people attack me like they would were it a real fight — this occasionally means that I get slugged or taken down. This was one of those times). Anyway, when we hit the floor I realized that there was no way I could contest this guys strength, he was a bull, full of muscle and grappling skill. The thing was I had landed next to a practice knife that I calmly picked up and dragged it across his throat.

We stood up and his eyes were the size of saucers because he realized what the significance of what had just happened. A knife had come out of nowhere and had this been real, he would have been dead. The amazing thing was is there were only a few other people there who did too. On of the bigger proponents of grappling stood  there and said, “He tackled you.” To which I replied, “Yes, and I slit his throat” “But, he tackled you.”

In their minds there was no difference in the levels of damage. The fact that I had been taken down counted the same as a knife across the throat. Personally, I’ll take getting slammed to the ground any day over getting my throat slit.

The myth of grappling is that it works everywhere. The fact that it proved so successful in the UFC ring has blinded many people to the fact that there are critical differences between fighting barehanded and fighting with weapons. While empty-hand fighting might easily turn into an endurance marathon, where size, strength, physical shape and ability to endure punishment  significantly influence the outcome of an altercation, that is not applicable to weapons work. In that arena, every man bleeds the same.

Oh yeah, remember how I said bio-mechanical cutting did have validity to it about the damage a knife can cause? What makes you think you can keep on fighting with that kind of damage being done to you? All a guy has to do is cut you a few times to seriously reduce your ability to move and then wait while you bleed out. Now the really bad news, being pumped up on adrenalin is going to make that happen faster,  the higher your heart rate, the faster you bleed out and lose strength. All he has to do is out wait for your strength to fail before finishing the job.

Do not attempt to “grapple” with a knifer. Once on the ground, you are not guaranteed to be able to control his knife arm well enough to prevent him from carving you up. If it were a barehanded fight, then you can often prevent him from being able to generate enough power to effectively strike you, but a knife doesn’t need power, it just needs to touch you. And if you are attempting to control his arm while on the ground, he will wiggle free and repeatedly cut you until you can no longer continue to resist.

Now for the fun news, I know of a small knife being manufactured that is called the “clinch pick.” A small concealable — and easily accessible — knife, that can be rammed into a grappler’s guts and chest three or four times before the grappler knows it is there. Where it is carried makes it nearly impossible for the grappler to prevent its deployment. When you realize he has it, it is too late.

Lie #11 The knife is an extension of your hand
This lie is most often promoted by empty-handed stylists who insist that they can teach you how to either defend yourself against a knife or to use one. Unfortunately, many people who started out in such systems have transferred over to supposed blade arts and continued promoting this often misinterpreted saying.

Empty hand fighting is not the same as weapon fighting — it requires different body mechanics, different ranges , different timing and — most importantly — an emphasis on movement that is not found in most kicking and punching arts. At least not in how they are taught in Westernized countries.

This emphasis on the hand largely stems from the sports influence of modern martial arts. However,  the problem is that most empty handed fighters lack the understanding of how to generate force from a moving state, instead seeking to generate force from a stationary/rooted stance and a twisting the hips. While this works for barehanded fighting styles, it fails to address the needs of weapons fighting.

It is my personal belief that the idea that the “knife is an extension of your hand” encourages a lack of bodily movement, instead relying on the hand to do all your work for you. In these circumstances your not being cut relies on you speed and reflexes, rather than more reliable means. Basically, because you might not be fast enough to counter, parry or block what he is doing. I further believe that this lack of motion largely stems from attempting to extend — whether unconsciously or intentionally — the thought process of empty handed fighting into a field where it does not belong, or work.

For reasons beyond the scope of this Web page I prefer the more encompassing and flexible term: The knife is an extension of your will.

What I will say is that if it is an extension of my hand, my body may or may not move. However,  if it is instead my will, everything in between  my will and my knife will be likely to move to achieve my ends. And that is far more effective for staying alive.

Lie #12 There is such a thing as a master knife fighter
Despite all the fantasy self-defense scenarios so-called “knife experts” concoct in their minds and are always talking about — where they would be justified in using a knife on another human being — the flat-out truth is that in 99.9% of the times that a knife is used on another human being it is a criminal act. Not to burst anybody’s bubble here, but those famous challenges and death matches that the old maestros engaged in were wildly illegal — both in the United States AND in the Philippines.

Now having said that I will be the first to point out that hot-headed, young bucks looking to prove themselves will often engage in extremely stupid, dangerous and criminal behavior in the name of pride or anger. But you know what? If they live, they often wind up in jail, if not prison. The law tends to frown on fights, much less duels.

Something Brian Curl, the cameraman on my knife videos and ex-SEAL said to me that I will always remember is “There ain’t no such thing as a professional knife fighter.” Truer words were never spoken. Nobody gets paid for knife fighting. On top of this, you don’t survive multiple knife fights without getting carved up pretty badly yourself. But most importantly, long before you stacked up enough murders to be qualified as a “master knife fighter” you would have found yourself on death row.

So look long and hard at anyone calling themselves a blademaster, knife fighter or knife fighting expert…because more likely than not, it is a self-imposed title that has no bearing on reality. And if he were such a master knife fighter, how come he ain’t got more scars and isn’t in prison?

Lie #13 That this is a “fight” at all
If you want to live, you don’t go in with a “fighting attitude” to any altercation involving weapons.

Weapons take it out of the arena of fighting and put it in the realm of combat.

And if you aren’t ready to go there, there is no shame in that. But don’t let your pride or anger push you into there, because the rules are totally different, and if you don’t know that, then you are the one who is going to get hurt.

If you see a weapon deployed, run. If you stay, don’t even think of fighting. It left that three counties back…someone is going to get seriously hurt if you stay. Now the question is, will it be him or you? Or both?

Lie #14 Expect to get cut
Remember that thing called bio-mechanical cutting? I said the major problem with it is on the legal front, but, on the “a knife is going to do a shitload of damage to you” front there’s a lot to be said for it. What amazes me is that some people can talk about the damage that their knife will do to an attacker, but at the same time blurt out the old clich?of “expect to get cut” as though  getting cut were only a minor inconvenience.

HELLO! Wake up and smell the coffee!!!!!

Where I really hit the roof on this mindset is when I see someone who comes from a empty hand fighting system attempt to “fight” an armed opponent in the same way that he would an unarmed opponent.

The thing is, these same people are the ones who often talk about “expecting to get cut.” And then, having said that, they take no effective measures to prevent it from happening! I have literally seen such people wade into a cuisine-art.

Now who ever came up with that term originally was speaking about a very important idea. That is that you will be cut in a blade altercation and that you need not to panic when it happens and that you must continue on to the best of your abilities in order to increase your chances of survival. To that intent and meaning I say “Amen!” I couldn’t agree more.

However, like the idea of biomechanical cutting has been bastardized by people into a dangerous misconception, so has this one. In fact, from having watched people who study so-called “blade arts” many of them have apparently taken it to mean allow yourself to be sliced up, making no effective defensive moves in order to try to get in one good hit. Apparently, if you nick him once to his twenty seven slashes, it is an acceptable exchange rate.

The other side of the pendulum swing is however, overly focusing on trying to control his knife arm before entering. Hanging back and trying to catch this fast moving blade so you can safely enter is one of the best ways I know to make getting cut a self-fulfilling prophecy.

This is  what really results from trying to extend a “fighting mindset” into weapons combat. It simply just does not work. Would you like to hear our philosophy on this subject?

Trade a cut for a kill, but nothing else.

That’s the difference between fighting and combat.

Lie #15 The FMA are the ultimate knife fighting systems
Let me lay it out on the line here. When it comes to knife fighting, they are all fucking dangerous.

There is no “sun source” of knife fighting. There is no land of ultimate knife fighting arts. There is no race who hold the monopoly on the “right way” to use a knife. As I said, I have traveled around the world and seen knife fighting systems from even more places and what I will tell you is that each of them will make you just as dead, just as quick.

What I will be the absolute first to admit is that the FMA have done wonders for organizing and explaining the ideas behind how they do what they do. And for that I take my hat off to them. And I salute and respect the skill and prowess of their eskrimadors, kali gurus and arnis masters. But I draw the line at even sitting quietly when someone tries to elevate one group of fighting skills above all others so they can swagger around saying that they study the ultimate “knife fighting” system. This above my immediate gag reflex when someone — who has never faced a knife in the hands of someone who wishes him ill — swaggers around and tells me that he knows everything there is to know about knife fighting because he studies under …………………..(fill in the blank).

There is no right way, one way or only way to use a knife…and the more you know about all the different ways the more likely you are to be able to come up with an effective counter if you are attacked in one of those ways. But if you have only studied one system, the odds are against you being able to come up with something that works. And I have to tell you, although Western practitioners like to claim that the FMAs do, those arts don’t cover all the ways a knife can be used on you. There is literally a world full of differences out there.

I have said it before and I will say it again: *Nobody* has a monopoly on the truth about knife fighting. The whole of the subject is just too big. Everybody has a slice of the pie. And learning what they have to say about it and how they do it where they are from is the best way for you to increase you chances of survival.

Lie #16 It’s easy to disarm an armed opponent
Every time I hear someone say this, I cringe. Because A) they have just told me that they have never dealt with someone intent on trying to kill them. B) Odds are that they are a bully and braggart. And C) If they are teaching people this nonsense they are going to get someone killed.

In a very real sense, someone standing there brandishing a knife is not trying to kill you…he is trying to scare you away. Now I will admit that it is often easier to overwhelm such a person because he is not in attack mode, but it is never easy. Such people can be surprised and often they cannot react in time. However, someone who is genuinely intent on attacking you with a blade is *never* easy to disarm or overcome. And promoting this lie is literally begging to get someone killed – especially if they encounter a committed attacker.

The problem that I have encountered with bullies is that they are very selective on who chose to bully. I have seen individuals who have savaged weaker opponents — as if by magic — disappear when trouble starts with true hard-cases. These individuals may have taken blades away from intimidated kids, but somehow they never seem to be around to try it against someone who is an experienced and hardened streetrat or former convict.

So again, proving that the exact choice of words is important we are left with a small, but important modification of what is commonly taught and what needs to be said: The concepts behind disarming an armed opponent are simple, they are not, however, easy — and neither is the actual disarm itself

Lie #17 You can successfully fight an armed attacker
This entire page has been dedicated to disproving this lie. The main reason it is a lie is that you cannot “fight” an armed opponent. You can survive against one and you might even be able to successfully put him down before he causes you any major damage…but, whatever you do, it must be fast, effective and brutal. If it isn’t, then you will not stop him before he causes you major damage.

You cannot stand there and engage in a long, drawn out contest with an armed opponent. If you try to do so, you will lose. It is not a matter of if, but of when.

Simply stated, every the touches you with the knife he will cause serious damage. How can you hope to launch a long drawn out retaliation against him when every time he touches you he causes “biomechanical cutting” on you? You are going to bleed out and cease to function long before your strategy comes to fruition.

Lie #18 Drills teach you how to knife fight
Drills teach principles. They teach ideas. They are the map, not the territory.

Unfortunately, many people mistake the map for the territory. One of the most unrealistic tendencies that drills teach is they do not teach you proper ranging. The object of an attack is to stab/slash your partner. However, often in training you will see people standing back ranging their attack against their partner’s stick or their training knife falling at least a foot short of their partner. Furthermore they are not attacking with the same commitment and force level that a real knife assault will occur with. Therefore the training drill, while important is missing several critical components.

Lie #19 You can use a knife on another human being without legal repercussions
I have seen videos by so-called “knife fighting masters” who actually show the fool encouraging his students to slash someone with a knife for trying to slug the student. I have also seen videos where after disarming their attackers with several slashes to the arm, these knife killers proceed to slash their — no longer armed — attacker to ribbons. I have stood in a convention hall and seen a martial artist doing a demo, leap back while slashing the weapon arm of his attacker, and then .. after “defanging the snake,” he leap back into range and executed a disemboweling move on his … now… unarmed former attacker. Later, when I asked him about if he understood that any student doing that move would be committing manslaughter instead of “self-defense” his eyes bugged out because he’d never considered how that move would be viewed in court. I have stood in my front room with attorneys and use of force experts and watched a tape on knife fighting where a supposed “expert,” not only starts a bar fight, does a suicide move that would have gotten his throat slit and then kneels down and stabs a downed  opponent — in front of witnesses! Actions  that everyone agreed would be prosecuted as  murder.

As such, don’t even get me started on the bozo’s who insist their students cut a person multiple times because “one cut may not stop him.” Unfortunately, this kind of training often goes awry when the attacker attempts to withdraw and the knife fighter keeps on slashing, even after the ex-attacker has turned his back on the knife fighter. Now, this once upon a time attacker has been slashed many times after he was disarmed and is slashed more on his back while attempting to retreat…guess who is going to go to prison for attempted murder?

A knife is considered a lethal force instrument…and the use of lethal force is *very* narrowly approved. If you use one another human being you had better damned well be firmly within those parameters…if not, then you are — in the eyes of the law and society — the bad guy.

Before you even think of picking up a knife for “self-defense” go out and take a course on Judicious Use of Lethal force. Do NOT take any knife fighting experts word on the subject, go to the source lawyers and expert witnesses on use of force

The only place where the knife fighting fantasy exists
is in the martial arts. There is no such thing in the modern
civilized world. In legal terms it is attempted murder,
assault with a deadly weapon or homicide. To the streetfighter
it is assassination, not a “fight” at all. To the criminal it is a tool
for robbery Everyone else considers it abhorrent macho stupidity.


Technical Solutions for Common Problems in TEVAR:


Technical Solutions for Common Problems in TEVAR:

Managing Access and Aortic Branches


Thoracic endovascular aortic repair (TEVAR) is rapidly emerging as an important treatment option for several indications, and it would not be unreasonable to predict that endograft treatment may well become the predominant form of therapy for many, if not the majority, of patients. However, several unresolved issues remain, and the need for further improvements and technological refinements will not cease any time soon. Ranking high among these issues are the challenges related to endovascular access and aortic branch management, which constitute the main focus of this review.

Achieving safe and successful endovascular access for introduction and deployment of the stent-graft device is a crucially important and often challenging step during TEVAR, but arterial injury has been, and continues to be, an all-too-common occurrence to this day. A clear understanding of the relevant issues and available technical solutions can go a long way toward preventing such catastrophes.

A preponderance of thoracic aortic pathologies tend to develop adjacent to or within the branched segments. It is therefore not surprising that branch management issues have risen to the top of the entire TEVAR field. Debranching and vessel relocation techniques have added a whole new dimension to the therapy because they can expand or create suitable landing zones proximally and distally, thereby broadening the applicability of endograft technologies to a much larger number of patients.

Keywords: thoracic aorta, stent-graft, thoracic endovascular aneurysm repair, vascular access, arch branch vessels, common carotid artery, left subclavian artery, external iliac artery

2008 was the “coming-out” year for thoracic endovascular aortic repair (TEVAR), as 2 additional stent-graft devices (Cook TX2 and Medtronic Talent) received marketing approval in the US. They joined the Gore TAG stent-graft, which was the first to be granted regulatory approval in 2005.13 The therapy overall is just beginning to reach a level of maturity, as the 3 major thoracic endograft manufacturers now aggressively support this technology. Many more physicians are likely to be trained in the required knowledge and skills necessary to perform thoracic endograft procedures. No doubt, many more patients will be offered such interventions in the future, and a true “revolution” (of sorts) in the field of thoracic aortic surgery looms on the horizon. TEVAR is rapidly emerging as an important treatment option for several indications,4 and it would not be unreasonable to predict that endograft repair may well become the predominant form of therapy for many, if not the majority, of patients (Table). Indeed, it is poised to eclipse the current open surgery standard of care, which has been dogged by continued high morbidity and significant perioperative mortality. Focal lesions in the mid descending thoracic aorta and perhaps blunt trauma injuries at the isthmus represent some of the most compelling indications for TEVAR; in such cases, the endovascular approach seems headed for “total triumph” and likely will replace surgical treatment in the near future. However, the reader is forewarned of the fact that these predictions may be somewhat premature, as we still lack the kind of scientific evidence that is generally required before a new therapy becomes truly a “game-changer” and replaces a time-honored standard of care.4

The above statements notwithstanding, several unresolved issues remain, and the need for further improvements and technological refinements will not cease any time soon. Ranking high on this list are the challenges related to endovascular access and aortic branch management, which constitute the main focus for this review.


Achieving safe and successful endovascular access for introduction and deployment of the stent-graft device is a crucially important and often challenging step during TEVAR. The reasons are twofold. First, currently available thoracic endografts have a large profile: for instance, for a 40-mm-diameter device, the TAG is 27.6 F (introducer sheath required), the TX2 is a 25.5-F device (sheath not required), and the Talent is 24 F (sheath not required). Second, female patients, with their notoriously small iliac and femoral arteries, make up a very significant segment of the TEVAR patient population (>30%5). Consequently, arterial access injury has been, and continues to be, an all-too-common occurrence, with external iliac artery (EIA) rupture ranking high as a cause of procedure-related mortality to this day. A clear understanding of the relevant issues and available technical solutions can go a long way toward preventing such catastrophes.

♦ (A) A focal aneurysm in the mid portion of the descending thoracic aorta is ideally suited for endovascular treatment. (B) Assessment of arterial access anatomy by CTA.

Vascular Access AnatomyHelical computed tomographic angiography (CTA) has emerged unequivocally as the most useful modality for detailed assessment of access arterial anatomy, overtaking axial CT and digital subtraction angiography (DSA).69 CTA displays with sharp precision the course and appearance of all vessels of interest and provides the necessary tools for sizing and measurements (Fig. 1B). While conventional DSA is still in use, it is undeniably falling out of favor because of its invasive nature and relative inaccuracy. After all, it can provide images of only the luminal silhouette, “ignoring” altogether the all-important vessel wall. However, on the plus side, intravascular ultrasound (IVUS) can enhance angiography’s capabilities by displaying with elegance and accuracy the arterial wall and its components. Furthermore, IVUS-generated arterial measurements are widely acknowledged to be quite accurate,10 although many experts in the field find it less attractive for aortic sizing and device selection because it tends to underestimate diameters (compared with centerline CTA measurements). IVUS is especially useful in urgent or emergent situations when there is no opportunity for detailed preoperative CTA assessment. Magnetic resonance angiography (MRA) has also been shown to be of value in such cases.
Transfemoral AccessIntroduction and delivery of the endograft device through the femoral artery is the acknowledged standard technique for TEVAR, feasible in at least 70% of cases overall. By the same token, a significant number of patients (as many as 30%) are found to have iliac artery anatomy and/or disease that may preclude transfemoral access. The vessel is usually exposed via surgical cutdown in the groin, but increasingly, the percutaneous approach is being described and championed by experts.It obviates the need for a surgical incision and vessel exposure altogether.Key to the percutaneous technique is the ability to repair the large arterial hole created by the introduction of the device, which became possible with the development of the Perclose Prostar XL closure device. It is generally used in a “pre-close” manner, with placement of the sutures through the arterial wall prior to introduction of the large sheath or endograft delivery system.20 The sutures (initially left untied) are tied at the end to achieve hemostasis and arterial repair. A modified and possibly more attractive closure strategy has been recently reported that relies on the use of the more advanced Perclose Proglide device,still inserted in a pre-close manner, but featuring a much lower profile than the Prostar XL (6- versus 10-F). It may also be considered simpler to use with only 2 needles/1 suture as opposed to 4 needles/2 sutures for Prostar.There is an additional “percutaneous closure” technique, one that does not involve a direct arterial closure or repair. This approach relies on achieving fascial gathering using a large purse-string suture that is inserted through the tissue planes overlying the arterial puncture site via a small skin incision. It is mainly applicable to thin patients when the punctured femoral artery lies immediately beneath the fascia and skin, and it is probably effective and reasonable only when dealing with small and midsize puncture holes (<18 F). In the end, the “total percutaneous” technique has emerged as a conceptually and practically attractive access option, and it is likely to gain momentum in the future. However, the potential for complications, mainly, arterial injury and hemorrhage, is not insignificant.Careful case selection is paramount. The following findings should be viewed as contraindications to percutaneous TEVAR: marked obesity, especially the presence of a thick pannus in the groin region; dense scars from multiple previous surgical and/or percutaneous procedures in the target area; an anatomically high femoral bifurcation that would necessitate a suprainguinal arterial puncture; and severe atherosclerotic disease, particularly when associated with dense calcification.
Coons DilatorsThe use of graduated Coons dilators has been found to be an extremely valuable tool in situations when doubt persists despite detailed assessment of arterial access anatomy. The dilators are available in incremental 2-F sizes up to 24 F. They are introduced via the femoral artery puncture and then advanced gently (retrograde) over a stiff guidewire under fluoroscopic visualization. The aim is to probe or gauge, not necessarily dilate, the access arteries. The operator can thereby attain, safely and immediately, a very good understanding of the likelihood of success with introduction and delivery of the chosen TEVAR device. Just attempting to pass the device using a “try-to-see-if-it-works” approach should be strongly discouraged in this setting, for it is fraught with danger. The dilators can also be used to dilate, cautiously and gradually, borderline small but soft iliac arteries. During the total percutaneous access procedure, this can be done to create a sufficiently large tract (across the soft tissues and the arterial wall) that will not impede advancement of the large delivery system.
Inadequate Femoral AccessIn 10% to 30% of patients undergoing TEVAR, inadequate arterial access anatomy will be found, most often the EIA. Tapping into a more proximal larger vessel is the logical next choice, and the common iliac artery (CIA) is the target of most such efforts. On occasion, the distal abdominal aorta may be used as well.

Iliac Access ConduitA graft conduit anastomosed to the CIA constitutes the most frequently used non-femoral access option during TEVAR. The following basic technical description is based on the author’s >10-year experience with the use of access conduits for aortic stent-graft intervention.23 Retroperitoneal exposure of the CIA is achieved via an oblique incision in the lower quadrant of the abdomen. CTA assessment of CIA anatomy provides the necessary information to choose the better side for conduit-graft attachment: the 3 most important features are vessel size, calcification, and length . The least diseased, larger, and longer vessel should be targeted. The distal abdominal aorta may occasionally be the only reasonable or available target for graft anastomosis. We tend to use a similar incision in such cases, but with a wider-field retroperitoneal exposure. A left-sided incision is preferred for aortic exposure, for the same reasons that most surgeons choose a left-side flank approach when performing retroperitoneal abdominal aortic aneurysm (AAA) repair. A 10-mm-diameter Dacron graft is the conduit of choice because it is easy to use and provides a large enough lumen for introduction of all delivery systems (even the largest size), including passage of additional parallel diagnostic catheters if necessary. The anastomosis is end to side between the graft and the CIA. The conduit is exited through the abdominal wall via a small stab incision placed just above the inguinal ligament to provide a smoother angle of entry for device introduction and delivery). The operator now has (in-hand) a true and direct extension of the CIA. The subsequent steps are not different from those generally followed when accessing a native vessel

♦ (A) Choice of the right or left iliac artery should be based on anatomy and disease, targeting the longest, least-diseased, and largest CIA for conduit graft anastomosis. (B) A 10-mm Dacron graft anastomosed end to side to the CIA (left) exteriorized through a lower-placed stab incision (right). (C) TEVAR sheath and device placed via puncture of the side of the conduit. Note that the 5-F sheath and diagnostic catheter have also been inserted into the same conduit graft. (D) Oversewn conduit stump may appear like a pseudoaneurysm on CTA. (E) The iliac conduit has been retained as a permanent implant, brought down to the groin as an iliofemoral bypass.

  • Direct needle puncture of the Dacron graft and introduction of a soft-tipped, steerable, 0.035-inch guidewire (i.e., Bentson, Wholey, or similar) that is advanced under fluoroscopic guidance to the ascending aorta, followed by catheter exchange for the stiff TEVAR wire of choice (i.e., Lunderquist).
  • Next, a second (slightly higher) needle puncture is made to insert a 5-F short sheath (over a guidewire) directly into the conduit. The wire is then advanced retrograde (under fluoroscopy) to the aortic arch or ascending aorta and used to support introduction of a long pigtail catheter. The conduit is thus used for both delivery of the endograft system and introduction of the necessary diagnostic catheter, obviating the need for additional vessel punctures. The introducer (or access) sheath is next passed into and through the conduit over the stiff guidewire. A #11 blade is used to enlarge the graft puncture hole only slightly, allowing the introducer sheath itself to enlarge the opening as the device is carefully advanced in retrograde fashion. Such a technique, as opposed to a wide opening into the graft or introduction through the end of the conduit, facilitates the procedure significantly and minimizes blood loss

The iliac conduit is excised at the end, leaving behind only a short stub that is carefully oversewn with a running polypropylene suture. The stub should be of a length that comfortably allows placement of a clamp on the graft itself (not the native vessel or suture line), but not so long as to create a pseudoaneurysm-like image that may lead to confusion and unnecessary concern when visualized on CTA postoperatively

The iliac conduit technique is not without potential pitfalls and complications:

  • Retroperitoneal exposure of the CIA can be a very difficult operation on obese individuals and those who have had prior operations in the same region of the abdomen.
  • Densely calcified iliac arteries must be avoided.
  • Suture-line disruption can and does happen on occasion while passing large rigid devices through relatively narrow anastomotic openings, especially when the CIA is small and/or diseased and thin-walled. We find it helpful to support and actually hold the anastomosis with one’s hand during such maneuvers.

If necessary, the conduit graft can be retained as a permanent iliofemoral bypass when flow through the EIA appears compromised at the end of the procedure, or when the need for a redo or repeat future aortic endograft procedure is anticipated or felt to be likely because it would be easily accessible through a short femoral incision.

Direct Sheath Introduction Via the Distal Aorta or CIACarpenter24 proposed the technique of “direct sheath placement into the aorta or iliac arteries,” without use of a graft or conduit, as an access option for aortic stent-graft intervention when the device cannot be delivered via the standard transfemoral approach. The procedure involves only limited retroperitoneal exposure of the anterior surface of the distal abdominal aorta or CIA. At times, the proximal EIA may be an appropriate target if the vessel is large enough and relatively free of atherosclerosis. Two non-penetrating adventitial purse-string sutures (polypropylene) are placed in opposing concentric circles at the site of intended puncture and sheath insertion. Arterial puncture is then performed at the center of the sutures, which is followed by guidewire introduction and, eventually, insertion of the large sheath for stent-graft delivery. Following withdrawal of the sheath, the purse-string sutures are tied, and additional simple sutures can be placed as needed to achieve perfect hemostasis. Alleged advantages over the more commonly used iliac conduit technique would include simplicity and speed, and, mainly, eliminating the need for wide exposure and complete vascular control. However, disadvantages exist as well, chief among them being the difficulty in obtaining a smooth entry angle for the large sheath. This, in fact, may well be its most significant shortcoming. Attachment of a conduit graft provides a good opportunity for overcoming such difficulty as the graft can be easily exited through a more inferior stab incision to create a longer and much smoother angle

Other Transfemoral Access Techniques for Extensively Diseased and/or Small EIAsWhile techniques to gain endovascular access through the iliac arteries (or more proximally) have been used extensively and with acceptable success rates, it is important to recognize they all involve surgical retroperitoneal exposure of the iliac arteries and/or the distal aorta. Related morbidity is unquestionably higher than that of the groin-only procedure.25It makes sense, therefore, to focus on expanding the applicability of the transfemoral access, even to patients with extensive atherosclerotic disease and/or small femoral artery or EIAs. Essentially, two techniques have been described that may be worth considering:

  • Queral and Criado26 first described the technique of “retrograde iliofemoral endarterectomy facilitated by balloon angioplasty” in 1995. The underlying concept is that an angioplasty balloon, when inflated, can be used effectively as an instrument to disrupt and “dissect” heavy atheromatous plaques that may be lining the full length of the EIA. The procedure is completed with a combination of (endarterectomy) rings and clamp-mediated “blind” extraction through the open femoral arteriotomy. While the original indication was revascularization for treatment of ischemic limbs, Yano et al.27 used the same principles and tools to create a larger lumen that would allow access for delivery of an endograft system. They also introduced the concept of relining the lumen with a stented graft.
  • Yano et al.27 described construction of a homemade “endoluminal conduit” from a Palmaz stent sutured into a 6-mm polytetrafluoroethylene (PTFE) graft and backloaded into a 6-F delivery system. It was used on 5 patients with severe iliac artery disease to facilitate access for stent-graft intervention. More aggressive iliac artery dilatation could then be pursued, within the PTFE conduit, with little fear of uncontained arterial rupture. In truth, this description represented another application of the “stented graft” concept for treatment of aortoiliac occlusive disease championed by Marin et al.28 in 1994. A recent publication by Peterson and Matsumura29 described further refinements to the creation of such “internal endoconduits.” They used an iliac limb component of an AAA stent-graft device to reline the extensively disease EIA. The device was 14 cm in length and tapered from 16 mm proximally to 12 mm distally. Proximal fixation was within the relatively normal distal CIA (covering the hypogastric artery origin); distally, the endograft was brought down into the femoral region. Once in place, and having achieved complete exclusion of the full length of the EIA, the vessel could be aggressively dilated to a diameter of 12 mm or more . “Controlled rupture of the re-lined EIA” may be a more apt name to characterize the procedure. It seems that a 12-mm lumen is necessary for placement of a 24-F outer diameter introducer sheath. A smaller sheath would require less aggressive dilation. The technique has its merits as it can truly expand the capabilities of the transfemoral access. The potential downside of covering the hypogastric origin may be a moot point since this vessel is often severely stenosed or occluded in the majority of patients with extensive iliac artery disease. Furthermore, coverage of the hypogastric artery, as opposed to direct coil embolization of the vessel, tends to be very well tolerated.

♦ Iliac endoconduit technique: (A) The guidewire is advanced retrograde through the lumen of a severely diseased EIA, (B) with subsequent placement of a suitable covered stent or stent-graft (such as the iliac limb of an AAA endograft). (C) Aggressive balloon dilation of the endograft-relined EIA, up to a 12-mm diameter if necessary, results in a large transluminal endoconduit (D).

Antegrade Transcarotid AccessThere are occasional patients who present with situations that may be truly impossible for retrograde endovascular access to the thoracic aorta. Such unusual conditions tend to be the result of various combinations of unsuitable anatomy, significant calcified atherosclerotic disease, and previous endovascular and/or surgical procedures. Use of an antegrade transcarotid access may constitute a viable alternative for some of these.19,3133It is based on the observation that the proximal common carotid arteries (CCA) tend to be large and essentially free of disease, even in the setting of severe arterial atherosclerosis elsewhere. Both anatomically and geometrically, the right CIA tends to be the better choice, but the final decision (right versus left) should be based on careful assessment of the anatomy of the aortic arch and its branches.The technique begins with surgical exposure of the proximal right CCA through a short longitudinal incision that parallels the anterior border of the sternocleidomastoid muscle at the base of the neck. Retrograde needle puncture of the exposed artery allows passage of an access-type 0.035-inch guidewire. Because the wire will often go in the direction of the ascending aorta, a multipurpose or similar curved catheter can be used to steer it in the direction of aortic flow, down into the descending thoracic aorta.

Transcatheter exchange for a very stiff guidewire will (hopefully) result in a relatively gentle and navigable pathway for easy introduction of the large sheath down to the proximal portion of the descending thoracic aorta . TEVAR can then proceed in standard fashion, but attention must be paid to the design and configuration of the chosen endograft. While the TAG stent-graft can be placed (indistinctly) retrograde or antegrade, other devices may require preliminary re-loading into the sheath “upside-down,” representing clearly an off-label use for such a device. Following completion of endograft placement and balloon molding, the large sheath can be removed, and the CCA is repaired using standard vascular suturing technique. Cross-clamping of the proximal CCA for a few minutes is, of course, required, a maneuver that is generally felt to be well-tolerated by most if not all patients. Potential problems and pitfalls of this technique are:

  • The procedure is (or seems) “awkward” because it involves use of long wires and devices that will extend up from the patient’s neck region. Careful attention must be paid to operating room configuration and table setup.
  • Displaying and understanding arch branch anatomy with clarity and precision is obviously paramount. We have found both CTA and conventional angiography to be valuable in this setting. Certain configurations are particularly challenging or possibly risky, for instance, when the left CCA originates directly from the innominate artery (bovine anatomy). In such a patient, retrograde introduction through the right CCA could potentially impede flow in both carotid arteries.
  • Antegrade transcarotid access is only (potentially) useful for treatment of aortic lesions that are located distal to the aortic arch, ideally, in the mid descending thoracic aorta or lower.
  • Lastly, it is only fair to state that this technique is far from “accepted” or “conventional.” Some may argue its safety is unproven. However, preliminary and anecdotal reports, as well as our own limited recent experience with 3 cases, would seem to indicate that it does represent a viable and reasonable option for TEVAR access. However, it should probably be considered only in situations that preclude use of the more standard retrograde access options.


Endograft repair will likely become the preferred treatment option for patients presenting with aneurysms and other pathologies involving the non-branched segment of the thoracic aorta, if it has not already done so. However, challenges and unresolved issues abound because many aortic lesions tend to develop adjacent to or within the branched segments. It is, therefore, not surprising that branch management issues have risen to the top of the entire TEVAR field. Debranching and vessel relocation techniques have added a whole new dimension to the therapy as they can expand or create suitable landing zones (necks) proximally and distally, thereby expanding applicability of endograft technologies to a much larger number of patients. However, the aortic arch and visceral segments could not be more different when the issues of branch vessel accessibility and the invasiveness of the required extra-anatomical bypasses are taken into account.

Arch BranchesThe aortic arch has been acknowledged repeatedly as “the Achilles’ heel” of TEVAR, and the presence of branches is the main reason for such a designation. Mapping the various arch zones (Fig. 5) has proven useful for reporting and documenting the all-important proximal endograft fixation site. It also serves as a platform for discussion of arch branch-related issues. For instance, in our 12-year TEVAR experience with > 400 endograft thoracic implants, approximately three quarters of the cases involved a proximal fixation site within arch zones 1, 2, or 3. While “conquering Zone 0” is not generally considered to be within the realm of current endovascular capabilities,stent-graft placement in the mid and even proximal arch is being reported increasingly at present.36The left subclavian artery (LSA) is the vessel that must be dealt with most frequently. The potential consequences of endograft coverage of the LSA (without revascularization) relate to ischemia of the hindbrain, spinal cord, and ipsilateral arm. Currently, opinions and practice trends seem to be coming back full circle, with a majority of experts expressing the view that simple “overstenting” (exclusion) is probably borderline unacceptable in many patients and that revascularization should be performed more often than not to minimize or eliminate potentially serious complications.37Arm claudication is the most frequent consequence but tends to be self-limited, with a majority of patients experiencing significant improvement or symptom resolution within a few months. The need to perform a reintervention for treatment of persistent symptoms of disabling arm claudication is rare: in our experience of >65 instances of LSA exclusion by endograft, we have encountered only 2 such examples.The indications for LSA revascularization (prior to or at the time of TEVAR) are now quite clear and almost universally agreed upon: prior left internal mammary artery-to-coronary artery bypass operation, occluded or absent right vertebral artery, dominant left vertebral artery, or extensive endograft coverage of the thoracic aorta. Less commonly, anatomical anomalies (such as presence of an aberrant right subclavian artery) may also require preliminary revascularization. While the carotid-subclavian bypass is considered widely as the standard technique for LSA revascularization, we have for many years preferred the carotid-axillary bypass instead because of technical ease and the avoidance of potential lymphatic and nerve complications associated with subclavian artery exposure.More proximal device landing into the mid or proximal arch often implies the need for left carotid artery debranching. We have found the crossover right-to-left carotid-carotid retropharyngeal bypass  to be the most satisfactory technique for such purpose.

♦ The “arch map” has proven of value for documenting and reporting proximal fixation sites of TEVAR devices. Complexity of the procedure and its outcome tend to correlate mostly with the proximal implantation zone

Ligation of the left CCA just below the graft anastomosis is an important component of this procedure as well. The operation has proven sound and safe, with excellent long-term durability.While it is true that all these cervical bypasses (or transpositions) work well and serve their purpose, they also imply the need for additional operative procedures, some morbidity, and the potential for delaying the definitive repair of the thoracic aorta, sometimes by several weeks. These ideas, together with personal experience in 2 cases (in early 2002) where unintentional endograft coverage of the left CCA occurred (Fig. 7), became the foundation for a different perspective and practice vis-à-vis arch branch management during TEVAR. It has evolved into a strategy that focuses on branch vessel preservation instead of debranching. The technique, conceived initially as a troubleshooting maneuver, consists of stenting the vessel origin to re-establish or preserve normal antegrade flow by creating an antegrade parallel channel outside of the aortic endograft.39The expanded stent “breaks” the endograft seal to the aortic wall in that focal area adjacent to the vessel ostium, thereby re-opening an antegrade channel for normal branch flow. Access for the procedure is via percutaneous retrograde catheterization of the left CCA or LSA; a similar approach (right-sided) can be used for stenting of the innominate artery.Typically, a micropuncture technique is used for placement of a fine guidewire that is advanced into the ascending aorta. The wire can be placed “pre-emptively” in cases where encroachment of a given arch branch is possible. If stenting becomes necessary, or when it is part of the operative plan, the microaccess wire is then exchanged for a more standard 0.035-inch guidewire that supports placement of a short 6-F sheath. A 6-mm-diameter angioplasty balloon is advanced retrograde (over the wire), inflated across the vessel origin, and used as a sizing tool to enable selection of an appropriate balloon-expandable stent. In most cases, an 8-mm-diameter by 29- or 30-mm-long device has been used. A self-expanding nitinol stent may need to be considered when dealing with a very large vessel (>10-mm diameter). In either case, the proximal end of the stent (residing inside the lumen of the aortic arch) must be positioned flush with the proximal border of the endograft fabric (or more proximally) to ensure formation of a long enough antegrade channel for unimpeded normal flow into the branch vessel . Our experience with 20 such “chimney grafts” in the arch (8 left CCA and 12 LSA associated with Talent and TAG stent-grafts) has been quite encouraging and satisfactory; over a mean 24-month follow-up (range 1–60), all the stents have remained patent, with only 2 showing in-stent stenosis. While creating a proximal type I endoleak is the most frequently voiced concern related to this technique, we have not encountered any in our experience. In truth, there have been essentially no complications or problems whatsoever, and this is in line with the experience recently reported by Ohrlander et al. However, it is important to note that several unanswered questions surrounding chimney grafts remain, mainly, the potential for integrity issues or device damage as a result of interaction between the aortic endograft and the adjacent branch stent over the long haul. This is the main reason why such a strategy cannot yet be recommended for wide adoption. Proximal endoleaks can probably be avoided as long as there is still (in the aorta) a circumferential neck area for fixation and seal distal to the stent. Expansion of these concepts for the creation of longer conduits through the lumen of the aortic arch is beginning to be explored . Only a few such procedures have been recently performed using a self-expanding covered stent (Viabahn) that has been re-lined with bare metal nitinol stents to enhance crush resistance.The above-described techniques for partial arch debranching (or vessel preservation) are generally felt to be reasonable if they lead to the creation of a minimum 2-cm-long proximal neck distal to the innominate artery origin (or beyond) to optimize or enable endograft intervention. However, for those patients with lesions that involve most or all of the aortic arch, only total arch debranching will do if endovascular repair is to be performed. This is perhaps the only area in the entire debranching scenario where only little if any disagreement exists; most surgeons concur that an ascending aorta-based bypass to the innominate and left CCA (or all 3 branches) performed through a median sternotomy approach should be the prescribed strategy in most cases. The operation involves only side clamping of the aorta and tends to be well tolerated.Finally, for the occasional patient who cannot have or withstand a median sternotomy/ascending aorta bypass and, at the same time, has good aortoiliac arterial inflow, there is yet one additional extra-anatomical and completely extra-thoracic option for total debranching. It uses the femoral artery or EIA to construct a retrograde femoroaxillary bypass, with simultaneous axillary (or subclavian) artery to carotid bypass, a crossover graft to the opposite-side carotid artery, plus or minus bypass to the contralateral subclavian artery. Proximal ligation of all arch branches (below the graft anastomoses) is obviously necessary to prevent backflow endoleak

♦ (A) A patient with large ductus arch aneurysms that involved the subclavian artery; the left CCA origin is located a short distance proximally. (B) Percutaneous puncture of the left CCA, with placement of a 0.018-inch guidewire (arrow) into the ascending aorta. Note also the diagnostic catheter that was advanced from a left brachial artery sheath. (C) Once deployed, the thoracic endograft covered the carotid artery almost completely. (D) After placement of the 6-F sheath into the left CCA, a balloon-expandable stent was deployed across the origin of the vessel, with the proximal end of the stent flush with the proximal border of the aortic endograft fabric to create an antegrade channel for normal arch branch flow

♦ Potential technical options for placement of longer chimney grafts using covered-stent devices.

Visceral BranchesUnlike the branches of the aortic arch, where vessels are accessible relatively easily via retrograde catheterization or surgical exposure in the neck, or even in the chest through a median sternotomy, the anatomy of the visceral and renal arteries is such that exposure and vascular control can be achieved only via a major intra-abdominal operation. This is especially so for the renal arteries because of their depth, short length, and frequent involvement in the inflammatory process surrounding many AAAs, particularly those that are large and juxtarenal. Combined (hybrid) surgical and endovascular approaches are being used to facilitate endovascular treatment of some thoracoabdominal and pararenal/paravisceral AAAs. The so-called “octopus operation”  is an example of a debranching procedure that consists of extra-anatomical, non-aortic-origin bypasses to most or all of the visceral and renal arteries. It enables endograft relining (repair) of the thoracoabdominal aorta, including the visceral segment. The operation can be performed using a conventional midline inframesocolic approach or a combination of that technique (to deal with the superior mesenteric and left renal arteries) and right-to-left visceral rotation to facilitate exposure of and anastomoses to the right renal artery and hepatic branch of the celiac artery . While the procedure offers the possibility of performing endovascular repair in a branched segment of the aorta, it is not without challenge and controversy because of the involved technical complexities, procedure length, and associated morbidity and mortality, which can be quite high.As a result, its role today remains unclear and somewhat controversial. Perhaps extra-anatomical debranching should be reserved for those patients who are (really) medically unfit for open repair, or those in whom only 1 or 2 arteries require relocation, mainly the superior mesenteric artery (SMA) because it is unquestionably the easiest vessel to bypass extra-anatomically.Lachat et al.42 have described a new and creative technical solution to these problems. It relies on the principle of needle puncture/over-the-wire introduction and deployment of a small-diameter stent-graft (Viabahn) using a Seldinger-type approach that requires only limited vessel exposure because visualization and access to the anterior wall of the target artery is all that is necessary. The graft can then be easily attached to an inflow source, such as an iliac-based bypass or similar . The technique is particularly attractive for dealing with the renal arteries, and Lachat and colleagues have reported very encouraging results. However, it may not be “ready for prime time” until other centers report similarly good results.A more frequent dilemma relates to the safety of endograft coverage/exclusion of the celiac artery. A preponderance of opinion suggests that most patients can tolerate it well. However, there have been several anecdotal reports of serious or even catastrophic complications resulting from celiac artery coverage, so the issue remains a continuing cause for concern.43Unfortunately, efforts such as selective and non-selective angiography with or without ‘provocative’ tests (balloon-mediated occlusion of the celiac and/or SMA), among others, have failed to determine or predict the safety or danger of such a maneuver. Our experience has been encouraging, with 7 instances of celiac artery coverage by endograft and no clinically significant complication, but we must remain cautious and perform such a maneuver only when absolutely necessary.Another potential concern relates to the anatomical proximity of the celiac and SMA origins, which can lead to possible coverage of both vessels in the course of imprecise bottom-end deployment of a thoracic endograft. This has led us to adopt an adjunctive technique when facing such a situation. It consists of retrograde (transfemoral) catheterization of the SMA with placement of a catheter (over the wire) into the vessel that is kept in place until after deployment of the aortic endograft . Should the device encroach on the SMA origin, it would be relatively simple to rapidly dilate and stent the SMA origin to re-establish blood flow and avoid catastrophic intestinal ischemia.
♦ (A) Octopus operation with iliac artery–origin extra-anatomical bypass/debranching of all visceral and renal arteries to enable endograft repair of the thoracic and abdominal aorta. (B) Example of midline-approach extra-anatomical bypasses to SMA and left renal artery, and medial-rotation lateral approach for the celiac (hepatic artery) and right renal artery bypasses (courtesy of Dr. Kasirajan, Atlanta, GA, USA).
(AD) Lachat’s Vortec technique requires only limited exposure of the target vessel (renal artery) and use of a Seldinger-type technique for endovascular access and placement of covered stent (Viabahn). (E) Once the distal “anastomosis” is completed, the conduit can be attached conveniently to the inflow source of choice.
♦ Retrograde access into the SMA with over-the-wire placement of a catheter can be performed (pre-emptively) when unintentional coverage of the SMA origin is possible in the course of TEVAR involving overstenting of the celiac artery.