In Situ Laser Fenestration for Revascularization of the Left Subclavian Artery During Emergent Thoracic Endovascular Aortic Repair

Abstract

To present midterm outcomes of thoracic endovascular aortic repair (TEVAR) with laser fenestration to revascularize the left subclavian artery (LSA) as an alternative to debranching. Six symptomatic patients (3 men; mean age of 50 years) underwent emergent TEVAR with LSA revascularization via laser graft fenestration. Three patients had large thoracic aortic aneurysms (2 secondary to chronic dissection); 1 patient had an acute symptomatic type B aortic dissection, and 2 patients had intramural hematomas. Emergent TEVAR was carried out with deployment of a Dacron endograft over the orifice of the left LSA. Through retrograde brachial access, a 0.018-inch wire was placed at the ostium of the LSA followed by laser catheter fenestration of the graft. A 10-mm covered stent was deployed through the fenestration to traverse the endograft and LSA; the endograft portion of the covered stent was flared. Laser fenestration was successful in 5 of 6 attempts; 1 fenestration was abandoned secondary to an acute LSA takeoff in a type III aortic arch. In this case, the stent was placed as a snorkel to successfully revascularize the LSA with no adverse consequences. There were no fenestration-related complications and no neurological morbidity. At a mean 8-month follow-up (range 1-17), no patients had died, and all LSA stents were patent, with no fenestration-related endoleaks on imaging. In situ retrograde laser fenestration is a feasible and effective option for revascularizing the LSA during emergent TEVAR. Longer follow-up is necessary to determine the durability of this technique.