In Situ Laser Fenestrations of Aortic Endografts for Emergent Aortic Disease

Abstract

In situ laser fenestration (ISLF) is a novel endovascular technique which allows customization of a standard stent graft to a patient's anatomy. While most reported cases involve revascularization of the left subclavian artery (LSA), some centers have now reported their initial experience treating branches of the visceral aorta for aortic aneurysms. The aim of this study is to examine the adoption of ISLF in emergent aortic pathology at a specialized aortic center. Between December 2020 and February 2022, all patients who underwent ISLF as part of endovascular intervention for complex aortic pathology at a university hospital were identified. Cases were collected from a prospective aortic database with additional information obtained from a retrospective review of electronic hospital records. Fifteen patients (11 men and 4 women) underwent emergency ISLF, with a median age of 76years. Eleven presented with symptomatic or ruptured aortic aneurysms, three with acute complicated aortic dissections and 1 aortic traumatic transection. Most aortic aneurysms were thoraco-abdominal (n=7), with 1 arch, 1 thoracic, 1 supra-renal, and one-juxta-renal aortic aneurysm. ISLF was performed to revascularize the LSA in 8 cases, and branches of the reno-visceral aorta in 7 cases. All LSA ISLF cases had left brachial artery exposure. Femoral access was percutaneous in 14 of 15 cases. Technical success was 96.3% (26/27)). Median ischemic times were: superior mesenteric artery 7min, renal arteries 22min, and celiac trunk 43.5min. There were 2 early aortic/fenestration related reinterventions. There was no stroke and 1 death caused by heparin-induced thrombocytopenia within 30days. The majority of patients did not require intensive care admission (n=8). The median intensive care unit stay was 0days and hospital length of stay 18days. There was no fenestration endoleak or reintervention post discharge with a median follow-up of 168days. ISLF is a promising new technique that can show excellent technical results in experienced aortic centers, even during the learning curve. While custom-made devices with reinforced fenestrations are preferred in nonemergent situations, ISLF is a feasible option for complex aortic pathology in the acute setting when open surgery is not feasible.