In Situ Laser Fenestration for Arch Branch Revascularization During Emergent Thoracic Endovascular Aortic Repair: Effective and Durable

Abstract

Retrograde in situ laser fenestration of the left subclavian artery (LSA) or common carotid artery during emergent thoracic endovascular aortic repair (TEVAR) is an innovative method to revascularize arch branches for diverse thoracic aortic diseases. This study provides an update on our expanded experience with extended follow-up to determine the efficiency and durability of this technique. Patients who underwent TEVAR with aortic arch branch revascularization from 2009 through 2018 were retrospectively reviewed. After TEVAR, the endograft was deployed over a branch orifice, in situ retrograde laser fenestration was performed through retrograde access, and a balloon-expandable covered stent was deployed in the LSA or common carotid artery. Postoperative imaging with computed tomography angiography was performed to assess branch patency, endoleaks, and fenestration-related reinterventions. TEVAR with laser fenestration was successfully performed in 60 patients (38 men; mean age, 61 years) in an urgent or emergent setting for diverse thoracic aortic diseases including 16 ruptures. Seventeen had acute complicated type B aortic dissection, 15 had intramural hematoma, and 17 had chronic dissection. TEVAR was done in zone 0 in 2 patients, in zone 1 in 7 patients, and in zone 2 in 51 patients. A balloon-expandable covered stent was placed across the fenestration into 56 LSAs, 3 left coronary arteries, and 1 right coronary artery. Mean length of stay was 9 days. Mean follow-up was 2.44 years. In-hospital mortality was 8.3%. Stroke rate was 3.3% (2/60), and three had permanent paraplegia. Follow-up computed tomography angiography demonstrated 100% primary patency of branch stents. There was no type III endoleak, but three type IC endoleaks required early coiling (one) and late restenting (two) for a 5.45% fenestration-related major reintervention rate. In situ retrograde laser fenestration is a rapid, effective, and durable method to revascularize arch branches during emergent TEVAR. The high technical success, low fenestration-related morbidity and reintervention rate, and excellent branch stent patency support use of this versatile technique.