Favourable Outcomes of Endovascular Total Aortic Arch Repair Via Needle Based In Situ Fenestration at a Mean Follow-Up of 5.4 Months

Abstract

Endovascular repair of aortic arch pathologies remains challenging. Recently, needle based in situ fenestration (ISF) has shown great potential in endovascular total aortic arch repair (ETAAR). This study aimed to evaluate the feasibility, effectiveness, and safety of ETAAR via needle based ISF, and to present initial experience with this technique. Patients who met the inclusion criteria were enrolled in this prospective study. The supra-arch branches were manually punctured in a retrograde manner using liver biopsy needles (18 gauge/30cm) in the left common carotid artery (LCCA) and brachiocephalic trunk (BCT), and endo-puncture system or aspiration biopsy needles (21-gauge) in the left subclavian artery (LSA). All the branches were revascularised with bridge stents. Routine follow-up occurred at 1, 3, 6, and 12 months post surgery. Ten patients with arch pathologies underwent ETAAR. Revascularisation of three branches was successfully performed in eight patients, but attempts to create ISF in LSA were unsuccessful in two patients because of tortuosity and sharp angle. The time taken to establish ISF in LCCA and BCT was 100.4s and 489.6s, respectively. Bilateral regional cerebral oxygen saturation (RCOS) decreased after the arch endograft deployment (both, p<.001) and recovered to the pre-operative level once both carotid arteries were reconstructed (left, p=.0856; right, p=.6). The right RCOS was higher with the beneficial effect of extracorporeal circulation (after cTAGs deployment, p<.001; after LCCA revascularised, p=.0148) during the ischaemic period. In one case, the left iliac artery ruptured, but no ISF related or neurological complications occurred. An early follow-up (mean 5.44 months) CTA and ultrasound confirmed patency of all the branch grafts without any endoleak or migration CONCLUSIONS: This study demonstrated that ETAAR via needle based ISF, making full use of off the shelf devices and techniques, can be successfully performed in aortic arch pathologies with a favourable early outcome.