Patent Publication Number: US-2022226099-A1

Title: Docking graft for placement of parallel distally extending grafts assembly and method

Description:
RELATED APPLICATIONS 
     This application is a divisional application of U.S. patent application Ser. No. 16/585,722 filed on Sep. 27, 2019, the entire contents of which are incorporated herein by reference. 
    
    
     FIELD 
     The present technology is generally related to an intra-vascular device and method. More particularly, the present application relates to a device for treatment of intra-vascular diseases. 
     BACKGROUND 
     Aneurysms, dissections, penetrating ulcers, intramural hematomas and/or transections may occur in blood vessels, and most typically occur in the aorta and peripheral arteries. The diseased region of the aorta may extend into areas having vessel bifurcations or segments of the aorta from which smaller “branch” arteries extend. 
     The diseased region of the aorta can be bypassed by use of a stent-graft placed inside the vessel spanning the diseased portion of the aorta, to seal off the diseased portion from further exposure to blood flowing through the aorta. 
     The use of stent-grafts to internally bypass the diseased portion of the aorta is not without challenges. In particular, care must be taken so that critical branch arteries are not covered or occluded by the stent-graft yet the stent-graft must seal against the aorta wall and provide a flow conduit for blood to flow past the diseased portion. 
     SUMMARY 
     The techniques of this disclosure generally relate to an assembly including a docking graft. The docking graft includes a main graft defining a main lumen, a first internal lumen within the main lumen, a second internal lumen within the main lumen, and a main docking lumen within the main lumen. The first internal lumen is configured to receive a first bridging stent graft therein and the second internal lumen is configured to receive a second bridging stent graft therein. The main docking lumen is configured to receive a tube graft therein. The first internal lumen, the second internal lumen, and the main docking lumen are parallel to one another and extend an entire length of the docking graft from a proximal end of the docking graft to a distal end of the docking graft when the docking graft is in a relaxed (unstressed) configuration. The docking graft forms the foundation, or anchor device, for attachment of the first bridging stent graft, the second bridging stent graft, and the tube graft within the aorta. 
     In one aspect, the present disclosure provides an assembly including a docking graft. The docking graft includes a main graft defining a main lumen, a first internal sleeve defining a first internal lumen within the main lumen, and a second internal sleeve defining a second internal lumen within the main lumen. The main lumen, the first internal lumen, and the second internal lumen are parallel to one another and extend an entire length of the docking graft from a proximal end of the docking graft to a distal end of the docking graft when the docking graft is in a relaxed configuration. 
     In yet another aspect, the present disclosure provides a method including deploying a docking graft within the ascending aorta. The docking graft includes a main graft defining a main lumen, a first internal lumen within the main lumen, a second internal lumen within the main lumen, and a main docking lumen within the main lumen. A first bridging stent graft is deployed within the first internal lumen, a second bridging stent graft is deployed within the second internal lumen, and a tube graft is deployed within the main docking lumen. The first bridging stent graft, the second bridging stent graft, and the tube graft are parallel to one another within the docking graft and extend distally from the docking graft. 
     The details of one or more aspects of the disclosure are set forth in the accompanying drawings and the description below. Other features, objects, and advantages of the techniques described in this disclosure will be apparent from the description and drawings, and from the claims. 
    
    
     
       BRIEF DESCRIPTION OF DRAWINGS 
         FIG. 1  is a side perspective view of a docking graft in accordance with one embodiment. 
         FIG. 2  is a top perspective view of the docking graft of  FIG. 1  in accordance with one embodiment. 
         FIG. 3  is a plan view of a proximal end of the docking graft along the line III of  FIG. 1  in accordance with one embodiment. 
         FIG. 4  is a plan view of a distal end of the docking graft along the line IV of  FIG. 1  in accordance with one embodiment. 
         FIG. 5  is a top perspective view of sleeves of the docking graft in accordance with one embodiment. 
         FIG. 6  is a partial cross-sectional view in a direction perpendicular to a longitudinal axis of a main graft of the docking graft of  FIGS. 1-2  in accordance with another embodiment. 
         FIG. 7  is a vessel assembly including the docking graft after deployment in accordance with one embodiment. 
         FIG. 8  is a cross-sectional view of the vessel assembly of  FIG. 7  at a later stage during deployment of a bridging stent graft in accordance with one embodiment. 
         FIG. 9  is a side plan view of the vessel assembly of  FIG. 8  at a later stage during deployment of a bridging stent graft in accordance with one embodiment. 
         FIG. 10  is a cross-sectional view of the vessel assembly of  FIG. 9  at a final stage during deployment of a tube graft in accordance with one embodiment. 
         FIG. 11  is a side plan view of the vessel assembly of  FIG. 8  at a later stage during deployment of a bridging stent graft in accordance with another embodiment. 
         FIG. 12  is a cross-sectional view of the vessel assembly of  FIG. 7  at a later stage during deployment of a bifurcated graft in accordance with one embodiment. 
         FIG. 13  is a side plan view of the vessel assembly of  FIG. 12  at a later stage during deployment of a bridging stent graft in accordance with another embodiment. 
         FIG. 14  is a cross-sectional view of the vessel assembly of  FIG. 13  at a later stage during deployment of a bridging graft and a tube graft in accordance with one embodiment. 
     
    
    
     DETAILED DESCRIPTION 
       FIG. 1  is a side perspective view of a docking graft  100  in accordance with one embodiment.  FIG. 2  is a top perspective view of docking graft  100  of  FIG. 1  in accordance with one embodiment. Docking graft  100 , sometimes called a prosthesis and/or a trifurcating device, includes a main graft  102 , a first internal sleeve  104 , and a second internal sleeve  106 . Docking graft  100  includes a proximal end  108  and a distal end  110 . 
     As used herein, the proximal end of a prosthesis such as docking graft  100  is the end closest to the heart via the path of blood flow whereas the distal end is the end furthest away from the heart during deployment. In contrast and of note, the distal end of the catheter is usually identified to the end that is farthest from the operator/handle while the proximal end of the catheter is the end nearest the operator/handle. 
     For purposes of clarity of discussion, as used herein, the distal end of the catheter is the end that is farthest from the operator (the end furthest from the handle) while the distal end of docking graft  100  is the end nearest the operator (the end nearest the handle), i.e., the distal end of the catheter and the proximal end of docking graft  100  are the ends furthest from the handle while the proximal end of the catheter and the distal end of docking graft  100  are the ends nearest the handle. However, those of skill in the art will understand that depending upon the access location, docking graft  100  and the delivery system descriptions may be consistent or opposite in actual usage. 
     Main graft  102  includes graft material  112  and one or more circumferential stents  114  coupled to graft material  112 . Graft material  112  may be any suitable graft material, for example and not limited to, woven polyester, DACRON® material, expanded polytetrafluoroethylene, polyurethane, silicone, electro spun materials, or other suitable materials. 
     Circumferential stents  114  may be coupled to graft material  112  using stitching or other means. In the embodiment shown in  FIG. 1 , circumferential stents  114  are coupled to an outside surface of graft material  112 . However, circumferential stents  114  may alternatively be coupled to an inside surface of graft material  112 . Circumferential stents  114  are not illustrated in  FIG. 2  to allow visualization of sleeves  104 ,  106 . 
     Although shown with a particular number of circumferential stents  114 , in light of this disclosure, those of skill in the art will understand that main graft  102  may include a greater or smaller number of stents  114 , e.g., depending upon the desired length of main graft  102  and/or the intended application thereof. 
     Circumferential stents  114  may be any stent material or configuration. As shown, circumferential stents  114 , e.g., self-expanding members, are preferably made from a shape memory material, such as nickel-titanium alloy (nitinol), and are formed into a zig-zag configuration. The configuration of circumferential stents  114  is merely exemplary, and circumferential stents  114  may have any suitable configuration, including but not limiting to a continuous or non-continuous helical configuration. In another embodiment, circumferential stents  114  are balloon expandable stents. 
     Further, main graft  102  includes a proximal opening  116  at proximal end  108  of docking graft  100 , a distal opening  118  at distal end  110  of docking graft  100 , and a longitudinal axis LA 1 . A lumen  120 , sometimes called a main lumen, is defined by graft material  112 , and generally by main graft  102 . Lumen  120  extends generally parallel to longitudinal axis LA 1  and between proximal opening  116  and distal opening  118  of main graft  102 . Graft material  112  is cylindrical having a substantially uniform diameter in this embodiment. However, in other embodiments, graft material  112  varies in diameter. 
       FIG. 3  is a plan view of proximal end  108  of docking graft  100  along the line III of  FIG. 1  in accordance with one embodiment.  FIG. 4  is a plan view of distal end  110  of docking graft  100  along the line IV of  FIG. 1  in accordance with one embodiment. 
     Referring to  FIGS. 1-4  together, first internal sleeve  104  and second internal sleeve  106  are located within main graft  102 , i.e., are attached to the inner surface of graft material  112  and generally of main graft  102 . Sleeves  104 ,  106  are located within lumen  120  of main graft  102 . 
     First internal sleeve  104  includes a proximal opening  122  at proximal end  108  of docking graft  100 , a distal opening  124  at distal end  110  of docking graft  100 , and a longitudinal axis LA 2 . A lumen  126 , sometimes called a first internal lumen  126 , is defined by first internal sleeve  104 . Lumen  126  extends generally parallel to longitudinal axis LA 2  and between proximal opening  122  and distal opening  124  of first internal sleeve  104 . 
     Similarly, second internal sleeve  106  includes a proximal opening  128  at proximal end  108  of docking graft  100 , a distal opening  130  at distal end  110  of docking graft  100 , and a longitudinal axis LA 3 . A lumen  132 , sometimes called a second internal lumen  132 , is defined by second internal sleeve  106 . Lumen  132  extends generally parallel to longitudinal axis LA 3  and between proximal opening  128  and distal opening  130  of second internal sleeve  106 . 
     In accordance with this embodiment, longitudinal axes LA 1 , LA 2 , and LA 3  are parallel to one another. Generally, lumens  120 ,  126 ,  132  of main graft  102 , first internal sleeve  104 , and second internal sleeve  106  are parallel to one another and extend the entire length of docking graft  100  between proximal end  108  and distal end  110  when docking graft  100  is in a relaxed (unstressed) configuration. 
       FIG. 5  is a top perspective view of sleeves  104 ,  106  of docking graft  100  in accordance with one embodiment. Referring to  FIGS. 1-5  together, sleeves  104 ,  106  include graft materials  134 ,  136  and one or more stents  138 ,  140 , respectively. Graft materials  134 ,  136  are the same or similar to graft material  112  as discussed above. Further, stents  138 ,  140  are the same or similar to stents  114  as discussed above. 
     Graft materials  134 ,  136  define lumens  126 ,  132  of sleeves  104 ,  106 , respectively. Stents  138 ,  140  insure that lumens  126 ,  132  remain open and accessible for docking of branch grafts therein as discussed further below. 
     Graft material  134  and generally first internal sleeve  104  is cylindrical having a substantially uniform diameter D 1  in this embodiment. However, in other embodiments, graft material  134  and generally first internal sleeve  104  varies in diameter. 
     Similarly graft material  136  and generally second internal sleeve  106  is cylindrical having a substantially uniform diameter D 2  in this embodiment. However, in other embodiments, graft material  136  and generally second internal sleeve  106  varies in diameter. 
     In accordance with this embodiment, diameters D 1  and D 2  are equal, although diameter D 1  is greater or less than diameter D 2  in other embodiments, e.g., depending upon the branch graft to be located within sleeves  104 ,  106  and the vessels to be perfused therethrough. 
     In accordance with this embodiment, internal sleeves  104 ,  106  abut one another, e.g., are attached, along the entire lengths of internal sleeves  104 ,  106 . Internal sleeves  104 ,  106  are attached to graft material  112 , and generally to main graft  102 , by an attachment means  142 . Attachment means  142  includes stitching, adhesive, or other suitable attachment means. 
     In accordance with this embodiment, lumens  126 ,  132  are entirely defined by graft materials  134 ,  136 . Stated another way, graft materials  134 ,  136  are cylindrical and completely surround lumens  126 ,  132 . However, in other embodiments such as that discussed below with reference to  FIG. 6 , graft materials  124 ,  136  in combination with graft material  112  define lumens  126 ,  132 . 
       FIG. 6  is a partial cross-sectional view in a direction perpendicular to longitudinal axis LA 1  of main graft  102  of docking graft  100  of  FIGS. 1-2  in accordance with another embodiment. Referring now to  FIGS. 1-4, and 6  together, first internal sleeve  104  in combination with main graft  102  define lumen  126 . More particularly, graft material  134  of first internal sleeve  104  is attached by attachment means  142  to graft material  112  of main graft  102  to define lumen  126 . Similarly, graft material  136  of second internal sleeve  106  is attached by attachment means  142  to graft material  112  of main graft  102  to define lumen  132 . 
     For example, graft materials  134 ,  136  are portions of a single piece of graft material that is attached by attachment means  142 , e.g., sewn, to graft material  112  along three seams  602 ,  604 ,  606  that extend in a direction parallel to longitudinal axes LA 1 , LA 2 , and LA 3  and between proximal end  108  and distal end  110  of docking graft  100 . Accordingly, lumen  126  is defined by a portion of graft material  112  between seams  602 ,  604  and graft material  134  between seams  602 ,  604 . Similarly, lumen  132  is defined by a portion of graft material  112  between seams  604 ,  606  and graft material  136  between seams  604 ,  606 . 
     Referring again to  FIGS. 1-4  together, first internal sleeve  104  including lumen  126  and second internal sleeve  106  including lumen  132  are located within lumen  120  of main graft  102 . The remaining volume of lumen  120  of main graft  102  that is not occupied by sleeves  104 ,  106  is a main docking channel  144 , sometimes called a main docking lumen  144 . More particularly, main docking channel  144  is the portion of lumen  120  of main graft  102  that is not occupied by sleeves  104 ,  106 . In other words, main docking channel  144  is defined by the inner surface of graft material  112  and the outer surfaces of sleeves  104 ,  106 . 
     More particularly, lumen  120  of main graft  102  is divided into, or formed of, lumens  126 ,  132  and  144 . Lumens  126 ,  132 ,  144  are parallel to one another and extend the entire length of docking graft  100 . 
     Accordingly, main docking channel  144  extends the entire length of docking graft  100  from proximal end  108  to distal end  110 . Main docking channel  144  has a proximal opening  146  at proximal end  108  that is the area of proximal opening  116  of graft material  112  minus the areas of proximal openings  122 ,  128  of sleeves  104 ,  106 . Further, main docking channel  144  has a distal opening  148  at distal end  108  that is the area of distal opening  118  of graft material  112  minus the areas of distal openings  124 ,  130  of sleeves  104 ,  106 . 
     As discussed further below, main docking channel  144  is a channel for docking of a main tube graft therein. Further, lumens  126 ,  132  of internal sleeves  104 ,  106  are channels for docking of branch stent grafts therein and so are sometimes called docking channels  126 ,  132 . Generally, docking graft  100  is a docking device for attachment and securement in the aorta of a tube graft and branch stent grafts as discussed below. 
       FIG. 7  is a vessel assembly  700  including docking graft  100  after deployment in accordance with one embodiment. Referring to  FIG. 7 , the thoracic aorta  704  has numerous arterial branches. The arch AA of the aorta  704  has three major branches extending therefrom, all of which usually arise from the convex upper surface of the arch AA. The brachiocephalic artery BCA originates anterior to the trachea. The brachiocephalic artery BCA divides into two branches, the right subclavian artery RSA (which supplies blood to the right arm) and the right common carotid artery RCC (which supplies blood to the right side of the head and neck). 
     The left common carotid artery LCC arises from the arch AA of the aorta  704  just to the left of the origin of the brachiocephalic artery BCA. The left common carotid artery LCC supplies blood to the left side of the head and neck. The third branch arising from the aortic arch AA, the left subclavian artery LSA, originates behind and just to the left of the origin of the left common carotid artery LCC and supplies blood to the left arm. The left subclavian artery LSA and the left common carotid artery LCC are distal to the brachiocephalic artery BCA and are sometimes called aortic branch arteries distal of the brachiocephalic artery BCA. 
     However, a significant proportion of the population has only two great branch vessels coming off the aortic arch AA while others have four great branch vessels coming of the aortic arch AA. Accordingly, although a particular anatomical geometry of the aortic arch AA is illustrated and discussed, in light of this disclosure, those of skill in the art will understand that the geometry of the aortic arch AA has anatomical variations and that the various structures as disclosed herein would be modified accordingly. 
     Aneurysms, dissections, penetrating ulcers, intramural hematomas and/or transections, generally referred to as a diseased region of the aorta  704 , may occur in the aorta arch AA and the peripheral arteries BCA, LCC, LSA. For example, thoracic aortic aneurysms include aneurysms present in the ascending thoracic aorta, the aortic arch AA, and one or more of the branch arteries BCA, LCC, LSA that emanate therefrom. Thoracic aortic aneurysms also include aneurysms present in the descending thoracic aorta and branch arteries that emanate therefrom. Accordingly, the aorta  704  as illustrated in  FIG. 7  has a diseased region similar to any one of those discussed above which will be bypassed and excluded using docking graft  100  as discussed below. 
     Docking graft  100  is deployed into aorta  704 , e.g., via femoral access. For example, to deploy docking graft  100 , a guide wire is introduced via femoral access, i.e., is inserted into the femoral artery and routed up through the abdominal aorta, and into the thoracic aorta. 
     A delivery system including docking graft  100  is introduced via femoral access and is advanced into the ascending aorta  704  over the guidewire. The delivery system is positioned at the desired location such that the position of docking graft  100  is in the ascending aorta near the aortic valve AV. Docking graft  100  is then deployed from the delivery system, e.g., by removal of a sheath constraining docking graft  100 . In another embodiment, docking graft  100  is delivered via supra-aortic access. 
     Main graft  102  is located and fixed within aorta  704  such that distal end  110  is proximal of the brachiocephalic artery BCA. Accordingly, blood flow enters proximal opening  116  of main graft  102 , flows through lumen  120  of main graft  102  (including through lumens  126 ,  132 ), and exits distal opening  118  of main graft  102  and into aorta  704  thus perfusing the distal territories. 
     In accordance with this embodiment, docking graft  100  is deployed such sleeves  104 ,  106  are located along the convex upper surface of the arch AA. In  FIG. 7 , docking channels  126 ,  132 ,  144  are illustrated in a side by side arrangement along the convex upper surface of arch AA for clarity of illustration. Once deployed, docking graft  100  including main graft  102 , internal sleeves  104 ,  106 , and main docking channel  144  assume the shape of aorta  704  by the flexible design of docking graft  100 . 
       FIG. 8  is a cross-sectional view of vessel assembly  700  of  FIG. 7  at a later stage during deployment of a first bridging stent graft  802 , sometimes called a bridging stent, in accordance with one embodiment. Referring now to  FIG. 8 , bridging stent graft  802  is located within internal sleeve  104 , i.e., within docking channel  126 , and the brachiocephalic artery BCA. More particularly, bridging stent graft  802  self-expands (or is balloon expanded) to be anchored within internal sleeve  104  and the brachiocephalic artery BCA. 
     Bridging stent graft  802  includes graft material  804  and one or more circumferential stents  806 . Graft material  804  includes any one of the graft materials as discussed above in relation to graft material  112 . In addition, circumferential stents  806  are similar or identical to circumferential stents  114  as discussed above. 
     In one embodiment, bridging stent graft  802  is deployed via supra aortic access. For example, to deploy bridging stent graft  802 , a guide wire is introduced through the right subclavian artery RSA, and advanced into distal opening  124  of internal sleeve  104 . 
     A delivery system including bridging stent graft  802  is introduced via supra aortic access and is advanced into the brachiocephalic artery BCA and internal sleeve  104  over the guidewire. Bridging stent graft  802  is then deployed from the delivery system, e.g., by removal of a sheath constraining bridging stent graft  802 . 
     In one embodiment, a proximal end  808  of bridging stent graft  802  is adjacent or distal of proximal opening  122  of internal sleeve  104 . Accordingly, bridging stent graft  802  overlaps the entire length of docking graft  100  insuring good overlap and seal between bridging stent graft  802  and internal sleeve  104 . However, in other embodiments, bridging stent graft  802  does not overlap the entire length of docking graft  100 , but has sufficient overlap to insure adequate sealing. Bridging stent graft  802  is co-axial with internal sleeve  104  in accordance with this embodiment. 
     Upon deployment of bridging stent graft  802 , blood flow into internal sleeve  104 , i.e., proximal opening  122 , is bridged and passed into the brachiocephalic artery BCA through bridging stent graft  802 . As bridging stent graft  802  is deploy via supra aortic access, perfusion of brachiocephalic artery BCA is immediate and reliable thus minimizing the complexity of the procedure and the associated risks. 
       FIG. 9  is a side plan view of vessel assembly  700  of  FIG. 8  at a later stage during deployment of a second bridging stent graft  902 , sometimes called a bridging stent, in accordance with one embodiment. Referring now to  FIG. 9 , bridging stent graft  902  is located within internal sleeve  106 , i.e., within docking channel  132 , and the left subclavian artery LSA. More particularly, bridging stent graft  902  self-expands (or is balloon expanded) to be anchored within internal sleeve  106  and the left subclavian artery LSA. 
     Bridging stent graft  902  includes graft material  904  and one or more circumferential stents  906 . Graft material  904  includes any one of the graft materials as discussed above in relation to graft material  112 . In addition, circumferential stents  906  are similar or identical to circumferential stents  114  as discussed above. 
     In one embodiment, bridging stent graft  902  is deployed via supra aortic access. For example, to deploy bridging stent graft  902 , a guide wire is introduced through the left subclavian artery LSA, and advanced into distal opening  130  of internal sleeve  106 . 
     A delivery system including bridging stent graft  902  is introduced via supra aortic access and is advanced into the left subclavian artery LSA and internal sleeve  106  over the guidewire. Bridging stent graft  902  is then deployed from the delivery system, e.g., by removal of a sheath constraining bridging stent graft  902 . 
     In one embodiment, a proximal end  908  of bridging stent graft  902  is adjacent or distal of proximal opening  128  of internal sleeve  106 . Accordingly, bridging stent graft  902  overlaps the entire length of docking graft  100  insuring good overlap and seal between bridging stent graft  902  and internal sleeve  106 . However, in other embodiments, bridging stent graft  902  does not overlap the entire length of docking graft  100 , but has sufficient overlap to insure adequate sealing. Bridging stent graft  902  is co-axial with internal sleeve  106  in accordance with this embodiment. 
     Upon deployment of bridging stent graft  902 , blood flow into internal sleeve  106 , i.e., proximal opening  128 , is bridged and passed into the left subclavian artery LSA through bridging stent graft  902 . As bridging stent graft  902  is deploy via supra aortic access, perfusion of the left subclavian artery LSA is immediate and reliable thus minimizing the complexity of the procedure and the associated risks. 
       FIG. 10  is a cross-sectional view of vessel assembly  700  of  FIG. 9  at a final stage during deployment of a tube graft  1002  in accordance with one embodiment. Referring to  FIG. 10 , tube graft  1002  is deployed into main graft  102  and into aorta  704  and is attached thereto. More particularly, tube graft  1002  is deployed into main docking channel  144  and within main graft  102 . 
     Tube graft  1002  includes graft material  1004  and one or more circumferential stents  1006 . Graft material  1004  includes any one of the graft materials as discussed above in relation to graft material  112 . In addition, circumferential stents  1006  are similar or identical to circumferential stents  114  as discussed above. 
     Tube graft  1002  is deployed into main graft  102  and aorta  704 , e.g., via femoral access. For example, to deploy tube graft  1002 , a guide wire is introduced via femoral access, i.e., is inserted into the femoral artery and routed up through the abdominal aorta, and into distal opening  148  of main docking channel  144 , and more generally into distal opening  118  of main graft  102 . A delivery system including tube graft  1002  is introduced via femoral access and is advanced into main docking channel  144 , and more generally into lumen  120  of main graft  102  over the guidewire. Tube graft  1002  is then deployed from the delivery system, e.g., by removal of a sheath constraining tube graft  1002 . 
     In one embodiment, a proximal end  1008  of tube graft  1002  is adjacent or distal of proximal opening  146  of main docking channel  144  and generally of proximal opening  116  of main graft  102 . Accordingly, tube graft  1002  overlaps the entire length of docking graft  100  insuring good overlap and seal between tube graft  1002  and main graft  102 , first internal sleeve  104 , and second internal sleeve  106 . However, in other embodiments, tube graft  1002  does not overlap the entire length of docking graft  100 , but has sufficient overlap to insure adequate sealing. Tube graft  1002  is co-axial with main docking channel  144  in accordance with this embodiment. 
     In one embodiment, internal sleeves  104 ,  106  are configured to exert a higher radial force than the radial force of tube graft  1002 . As used herein, “radial force” includes both a radial force exerted during expansion/deployment as well as a chronic radial force continuously exerted after implantation such that a scaffold has a predetermined compliance or resistance as the surrounding native anatomy, e.g., the aorta  704 , expands and contracts during the cardiac cycle. The radial force of tube graft  1002  is configured to be lower than that of internal sleeves  104 ,  106  to avoid collapse of internal sleeves  104 ,  106  when tube graft  1002  is deployed against and adjacent thereof and thus maintain perfusion of internal sleeves  104 ,  106 . 
     To configure internal sleeves  104 ,  106  and tube graft  1002  with differing relative radial forces, circumferential stents  138 ,  140  of internal sleeves  104 ,  106  are constructed with relatively thicker and/or shorter segments of material than circumferential stents  1006  of tube graft  1002 . Shorter and/or thicker circumferential stents  138 ,  140  have less flexibility but greater radial force to ensure that circumferential stents  1006  of tube graft  1002  do not collapse lumens  126 ,  132  of internal sleeves  104 ,  106 . Other variations or modification of circumferential stents  138 ,  140 ,  1006  may be used to achieve relative radial forces in other embodiments. 
     In another embodiment, bridging stent grafts  802 ,  902  are configured to exert a higher radial force than the radial force of tube graft  1002 . For example, circumferential stents  806 ,  906  of bridging stent grafts  802 ,  902  are constructed with relatively thicker and/or shorter segments of material than circumferential stents  1006  of tube graft  1002 . Accordingly, bridging stent grafts  802 ,  902  prevent collapse of internal sleeves  104 ,  106  when tube graft  1002  is deployed against and adjacent thereof and thus maintain perfusion of internal sleeves  104 ,  106  including bridging stent grafts  802 ,  902  therein. 
     Upon deployment of tube graft  1002 , blood flow into proximal opening  146  of main docking channel  144  is bridged and passed into the aorta  704  through tube graft  1002 . In this manner, any overlapped diseased regions of the aorta  704  are excluded. 
     Generally, grafts  802 ,  902 ,  1002  are deployed in parallel within docking graft  100 . Docking graft  100  forms the foundation, or anchor device, for attachment of grafts  802 ,  902 ,  1002  to aorta  704 . Grafts  802 ,  902  are deployed via supra-aortic access after sub selecting each gate. Grafts  802 ,  902 ,  1002  extend distally in parallel from docking graft  100 . Although various features may be described as parallel, in light of this disclosure, the features may not be exactly parallel due to being deformed by and assuming the shape of aorta  704 . 
     In accordance with this embodiment, tube graft  1002  overlaps, excludes and thus occludes the left common carotid artery LCC. In accordance with this embodiment, a bypass  1010 , e.g., a bypass graft, provides perfusion to the left common carotid artery LCC. Illustratively, bypass  1010  provides perfusion of the left common carotid artery LCC from the left subclavian artery LSA. 
     Bypass  1010  is surgically inserted during the same procedure as deployment of docking graft  100 , grafts  802 ,  902 , and tube graft  1002 . However, in another embodiment, bypass  1010  is surgically inserted prior to deployment of docking graft  100 , grafts  802 ,  902 , and tube graft  1002 , e.g., to simplify the procedure. 
       FIG. 11  is a side plan view of vessel assembly  700  of  FIG. 8  at a later stage during deployment of bridging stent graft  902  in accordance with another embodiment. Vessel assembly  700  of  FIG. 11  is similar to vessel assembly  700  of  FIG. 10  and only the significant differences are discussed below. 
     Referring now to  FIG. 11 , bridging stent graft  902  is located within internal sleeve  106 , i.e., within docking channel  132 , and the left common carotid artery LCC (in contrast, in  FIG. 10 , bridging stent graft  902  is located left subclavian artery LSA). More particularly, bridging stent graft  902  self-expands (or is balloon expanded) to be anchored within internal sleeve  106  and the left common carotid artery LCC. 
     In one embodiment, bridging stent graft  902  is deployed via supra aortic access. For example, to deploy bridging stent graft  902 , a guide wire is introduced through the left common carotid artery LCC, and advanced into distal opening  130  of internal sleeve  106 . 
     A delivery system including bridging stent graft  902  is introduced via supra aortic access and is advanced into the left common carotid artery LCC and internal sleeve  106  over the guidewire. Bridging stent graft  902  is then deployed from the delivery system, e.g., by removal of a sheath constraining bridging stent graft  902 . 
     Upon deployment of bridging stent graft  902 , blood flow into internal sleeve  106 , i.e., proximal opening  128 , is bridged and passed into the left common carotid artery LCC through bridging stent graft  902 . As bridging stent graft  902  is deploy via supra aortic access, perfusion of the left common carotid artery LCC is immediate and reliable thus minimizing the complexity of the procedure and the associated risks. 
     Tube graft  1002  is deployed into main graft  102  and into aorta  704  and is attached thereto as discussed above. Tube graft  1002  overlaps, excludes and thus occludes the left subclavian artery LSA. In accordance with this embodiment, bypass  1010  provides perfusion to the left subclavian artery LSA. Illustratively, bypass  1010  provides perfusion of the left subclavian artery LSA from the left common carotid artery LCC. 
       FIG. 12  is a cross-sectional view of vessel assembly  700  of  FIG. 7  at a later stage during deployment of a bifurcated graft  1202 , sometimes called a first bridging stent graft  1202 , in accordance with one embodiment. Referring now to  FIG. 12 , bifurcated graft  1202  includes a main graft  1204  that is bifurcated into first branch graft  1206  and a second branch graft  1208 . First branch graft  1206  is longer than second branch graft  1208 , sometimes called a contralateral gate. 
     Main graft  1204  is located within internal sleeve  104 , i.e., within docking channel  126 , and first branch graft  1206  is located with the brachiocephalic artery BCA. More particularly, main graft  1204  self-expands (or is balloon expanded) to be anchored within internal sleeve  104  and first branch graft  1206  self-expands (or is balloon expanded) to be anchored within the brachiocephalic artery BCA. A distal opening  1210  of second branch graft  1208  is proximal to the left common carotid artery LCC. 
     Bifurcated graft  1202  includes graft material  1212  and one or more circumferential stents  1214 . Graft material  1212  includes any one of the graft materials as discussed above in relation to graft material  112 . In addition, circumferential stents  1214  are similar or identical to circumferential stents  114  as discussed above. 
     In one embodiment, bifurcated graft  1202  is deployed via supra aortic access after sub selecting the gate. For example, to deploy bifurcated graft  1202 , a guide wire is introduced through the right subclavian artery RSA, and advanced into distal opening  124  of internal sleeve  104 . 
     A delivery system including bifurcated graft  1202  is introduced via supra aortic access and is advanced into the brachiocephalic artery BCA and internal sleeve  104  over the guidewire. Bifurcated graft  1202  is then deployed from the delivery system, e.g., by removal of a sheath constraining bifurcated graft  1202 . 
     In one embodiment, a proximal end  1216  of bifurcated graft  1202  is adjacent or distal of proximal opening  122  of internal sleeve  104 . Accordingly, bifurcated graft  1202  overlaps the entire length of docking graft  100  insuring good overlap and seal between bifurcated graft  1202  and internal sleeve  104 . However, in other embodiments, bifurcated graft  1202  does not overlap the entire length of docking graft  100 , but has sufficient overlap to insure adequate sealing. 
     Upon deployment of bifurcated graft  1202 , blood flow into internal sleeve  104 , i.e., proximal opening  122 , is bridged and passed into the brachiocephalic artery BCA through bifurcated graft  1202 , i.e., through first branch graft  1204 . As bifurcated graft  1202  is deploy via supra aortic access, perfusion of brachiocephalic artery BCA is immediate and reliable thus minimizing the complexity of the procedure and the associated risks. 
       FIG. 13  is a side plan view of vessel assembly  700  of  FIG. 12  at a later stage during deployment of bridging stent graft  1302  in accordance with another embodiment. Referring now to  FIG. 13 , bridging stent graft  1302  is located within second branch graft  1208  and the left common carotid artery LCC. More particularly, bridging stent graft  1302  self-expands (or is balloon expanded) to be anchored within second branch graft  1208  and the left common carotid artery LCC. 
     In one embodiment, bridging stent graft  1302  is deployed via supra aortic access. For example, to deploy bridging stent graft  1302 , a guide wire is introduced through the left common carotid artery LCC, and advanced into distal opening  1210  of second branch graft  1208 . 
     A delivery system including bridging stent graft  1302  is introduced via supra aortic access and is advanced into the left common carotid artery LCC and second branch graft  1208  over the guidewire. Bridging stent graft  1302  is then deployed from the delivery system, e.g., by removal of a sheath constraining bridging stent graft  1302 . 
     Upon deployment of bridging stent graft  1302 , blood flow into second branch graft  1208  is bridged and passed into the left common carotid artery LCC through bridging stent graft  1302 . As bridging stent graft  1302  is deploy via supra aortic access, perfusion of the left common carotid artery LCC is immediate and reliable thus minimizing the complexity of the procedure and the associated risks. 
       FIG. 14  is a cross-sectional view of vessel assembly  700  of  FIG. 13  at a later stage during deployment of bridging stent graft  902  and tube graft  1002  in accordance with one embodiment. Bridging stent graft  902  is located within internal sleeve  106 , i.e., within docking channel  132 , and the left subclavian artery LSA in a manner similar to that discussed above regarding  FIG. 9 , and so the discussion is not repeated here for simplicity. Further, tube graft  1002  is deployed into main graft  102  and into aorta  704  in a manner similar to that discussed above regarding  FIG. 10 , and so the discussion is not repeated here for simplicity. 
     It should be understood that various aspects disclosed herein may be combined in different combinations than the combinations specifically presented in the description and accompanying drawings. It should also be understood that, depending on the example, certain acts or events of any of the processes or methods described herein may be performed in a different sequence, may be added, merged, or left out altogether (e.g., all described acts or events may not be necessary to carry out the techniques). In addition, while certain aspects of this disclosure are described as being performed by a single module or unit for purposes of clarity, it should be understood that the techniques of this disclosure may be performed by a combination of units or modules associated with, for example, a medical device.