Fenestration Technique Research Articles

Endovascular repair combined with in situ fenestration for new-onset or residual arch dissection in patients underwent aortic replacement.

Ascending aorta or hemi-arch replacement is a frequently used treatment for patients with acute type A thoracic aortic dissection, particularly those who are elderly or have multiple comorbidities. However, in cases where there are secondary entry tears in the aortic arch or descending aorta, this procedure may not fully resolve the issue. The true lumen may remain compressed due to perfusion of the false lumen and usually require reoperation. Between January 2019 and July 2022, 18 patients underwent endovascular total aortic arch repair and fenestration technique without requiring median re-sternotomy. Aortic stent grafts were implanted via the femoral approach, utilizing prosthetic vessels as an appropriate proximal landing zone for aortic stent graft deployment. Based on the debranching conditions of the arch in previous surgery, single, double or triple in situ fenestrations (ISFs) were performed, respectively. All 18 cases were technically successful, with a median follow-up period of 20 months (range: 18-31 months). All patients had a favourable postoperative course, with no deaths within 30 days or during their hospital stay. There were no instances of disabling stroke, paraplegia, endo-leak, stent graft migration or stent graft-induced new entry. In addition, all patients exhibited complete thrombosis of the false lumen at the level of the aortic arch. Our preliminary experience suggests that endovascular total arch repair combined with ISF technique is a viable, effective and safe option for treatment. Our mid-term results have been promising, but we acknowledge the need for further evaluation to assess long-term outcomes and durability.

Endovascular repair of thoracic aortic disease with isolated left vertebral artery and unfavorable proximal landing zone using fenestrated castor stent-graft.

The main purpose of this study was to evaluate the safety and efficacy of Castor single-branched stent-graft combined with fenestrated technique in treatment of thoracic aortic disease (TAD) with unfavorable proximal landing area (PLZ) and isolated left vertebral artery (ILVA). From January 2018 to March 2022, 8 patients with TAD (6 patients with type B aortic dissections, 1 patient with type B intramural hematomas, and 1 patient with thoracic aortic aneurysm) underwent thoracic endovascular aortic repair with fenestrated Castor stent-graft due to the existence of ILVA and unfavorable PLZ. Demographic characteristics, surgical details, postoperative complications, follow-up and postoperative CTA imaging results were collected and analyzed. The primary technical success rate was 100%. The mean operation time was 115 min (range, 70-180 min). All the left subclavian arteries (LSAs) and ILVAs of the eight patients were revascularized by fenestrated Castor stent-grafts. During the follow-up period, no deaths and complications were observed. No internal leakage, aortic rupture, retrograde type A dissection were found on computed tomography angiography. All of the LSAs and ILVAs maintained patency without stenosis. Castor single-branched stent-graft implantation combined with fenestration technique may be safe and feasible for TAD patients with ILVA and unfavorable PLZ.

Early and midterm outcomes of in situ fenestration via adjustable puncture needle for Ankura aortic stent graft: A single-center experience.

An analysis was conducted to demonstrate early and midterm outcomes of using adjustable puncture needle-based in situ fenestration (ISF) technique for Ankura aortic stent graft to reconstruct the supra-arch branch in thoracic endovascular aortic repair (TEVAR). A retrospective analysis of 68 cases of aortic lesions with insufficient proximal anchoring area admitted to our department from March 2017 to December 2021 was performed. In situ fenestration thoracic endovascular repair (TEVAR) was performed at the same time during the operation. Among them, there were fifty-eight cases of thoracic aortic dissection, seven cases of thoracic aortic aneurysm, and three cases of thoracic aortic ulcer. Intraoperative adjustable puncture with needle was used for the Ankura aorta stent graft to perform ISF and reconstruction of the supra-arch branch. The success rate of ISF was 94.1% (64/68). Only in four cases, attempts were made to create ISF in the left subclavian artery (LSA), and all the four were unsuccessful because of sharp and tortuosity angle. Among them, forty-four cases were only LSA fenestration, and one case was left common carotid artery (LCCA) fenestration + LSA embolism. LSA + left vertebral artery (LVA) fenestration was performed in two cases, LSA fenestration +LCCA chimney was performed in fourteen cases, LCCA + LSA fenestration + innominate artery (INA) chimney was performed in one case, and LCCA fenestration + INA chimney + LSA embolism was performed in two cases. The overall neurologic event rate was 3.1% (spinal cord ischemia 0, with stroke observed in two cases). Postoperatively, one patient (1.6%) died on the third day after TEVAR due to the retrograde dissections. There were four cases of endoleak (6.3%; three type I and one type II). The average follow-up was 29.2 ± 14.4months, and no patient died during the follow-up period. Three cases of endoleak disappeared, and one case did not increase further. In addition, other two cases of retrograde dissections were observed at 3 and 5months after TEVAR. Fortunately, they were scheduled for emergency surgery with ascending aorta replacement and improved well. There was only one case of LSA occlusion after ISF which was reconstructed by endovascular treatment. Two patients were found with distal stent graft-induced new entries (dSINE), and TEVAR was performed again during the follow-up period. Early and midterm outcomes demonstrated that ISF via the adjustable puncture needle device for the Ankura aorta stent graft is a feasible and effective treatment method, which can achieve high technical success and satisfactory short-term results.

Comparative study of surgical effects on patients with mixed deafness and otosclerosis with different air bone conduction differences

Objective: To analyze the surgical efficacy of patients with mixed hearing loss and otosclerosis with different air bone gap (ABG) before surgery, and to provide reference for the prognosis evaluation of otosclerosis surgery. Methods: The clinical data of 108 cases(116 ears) of otosclerosis who had undergone stapes fenestration technique artificial stapes implantation in Xiangya Hospital of Central South University from November 2013 to May 2020 and had mixed hearing loss before surgery were collected, including 71 women(76 ears)and 37 men (40 ears), with an average age of 38.5 years. According to preoperative pure tone audiometry ABG, they were divided into three groups: group S, 15 dB≤ABG<31 dB, a total of 39 ears; group M, 31 dB≤ABG<46 dB, a total of 58 ears; and group L, ABG≥46 dB, 19 ears in total. The hearing outcomes of three groups of patients at 6-12 months after surgery were compared and analyzed using SPSS 24.0 statistical software. Results: A total of 3 patients (group S: 2 cases; group L: 1 case) experienced severe sensorineural hearing loss after surgery and were not included in the statistical analysis. After surgery, the pure tone hearing threshold of patients with otosclerosis in each group was significantly improved compared to before surgery, with an average air conduction threshold improvement of(21.6±13.4) dB. The difference between before and after surgery was statistically significant(t=17.13, P<0.01). The average bone conduction threshold improved by(3.7±7.6) dB, and the difference was statistically significant before and after surgery(t=5.20, P<0.01). The postoperative ABG was(18.3±9.3) dB, which was significantly reduced compared to preoperative(36.2±8.6)dB. Among the three groups of patients, the L group had the highest improvement in air conduction threshold[(29.9±10.8)dB], while the S group had the lowest improvement[(15.7±11.4)dB]. There was no statistically significant difference in post operative pure tone hearing thresholds between the three groups(P>0.05). The postoperative ABG in group S was the smallest[(16.5±9.0)dB], while in group L, the postoperative ABG was the largest[(20.5±10.0)dB]. Compared with group S, group M and group L still had a large residual ABG at 2 000 Hz after surgery. The bone conduction threshold of both S and M groups improved to some extent after surgery compared to before (P<0.01). Conclusions: Surgery can benefit patients with mixed hearing loss and otosclerosis with different preoperative ABG. Patients with small preoperative ABG have better surgical results and ideal ABG closure at all frequencies after surgery. Patients with large preoperative ABG can significantly increase the gas conduction threshold during surgery, but certain frequencies of ABG may still be left behind after surgery. The improvement effect of surgery on bone conduction threshold is not significant. Patients should be informed of treatment methods such as hearing aids based on their actual situation for selection.

Efficacy of Fenestration Technique for Lumbar Disc Excision in Pain Relief

Objective: To determine the outcomes of lumbar disc excision by fenestration technique for pain relief in lumbar radiculopathy due to prolapsed intervertebral disc. Methodology: This is a descriptive study conducted in a joint venture of orthopedic and neurosurgeons in a private hospital of Lahore. Study was completed in six months duration from July to December 2022. All patients presenting with lower back pain, straight leg raise test positive on &lt;60 degrees and prolapsed disc at the level of L4/L5 or L5/S1 L discs on MRI. Those with multilevel disc prolapse, previous history of spinal surgery, cauda equine syndrome and patients with lumbar stenosis were excluded from the study. All study patients were operated under general anesthesia in knee chest position. Efficacy of the procedure was determined using Dennis Pain Scale. Important findings were documented when patient was discharged. SPSS version 20 was used for statistical analysis. Results: 125 patients were studied including 73(58.4%) males and 52(41.6%) females. Patients with the age of 20-60 years were included in this study with the mean age of 47.3 ± 5.2 years. Most commonly involved disc level was L4-L5 in 77(61.6%) and L5-S1 in 48(38.4%) cases. Unilateral radicular pain was present in 94(75.2%) cases and bilateral pain was present in 31(24.8%) cases. According to Dennis Pain Scale out of 125 cases 78(62.4%) patients presented in Dennis pain scale P4 and among them complete recovery achieved in 70(89.7%) cases. Conclusion: Surgical intervention is necessary in selected patients with prolapsed intervertebral disc with chronic unilateral or bilateral radicular pain. Fenestration technique for disc excision is a very good procedure for prolapsed disc. Keywords: Sciatica, Disc Excision, Prolapsed Disc, Radiculopathy

Homemade fenestration and chimney techniques for the left subclavian artery revascularization during zone 2 thoracic endovascular aortic repair.

To investigate the safety and efficacy of homemade fenestration and chimney techniques for the left subclavian artery (LSA) revascularization during zone 2 thoracic endovascular aortic repair (TEVAR). From February 2017 to February 2021, 41 patients undergoing fenestration technique (group A) and 42 patients undergoing chimney technique (group B) to preserve the LSA during zone 2 TEVAR were enrolled in the present study. The procedure was indicated for dissections with unsuitable proximal landing zone with refractory pain and hypertension, rupture and malperfusion, and high-risk radiographic features. The baseline characteristics, peri-procedure, and follow-up clinical and radiographic data were recorded and analyzed. The primary endpoint was clinical success, and the secondary endpoints were rupture-free survival, LSA patency, and complications. Aortic remodeling, defined as patency, partial and complete thrombosis of the false lumen, was also analyzed. Technical success was achieved in 38 and 41 patients in groups A and B, respectively. Four intervention-related deaths were confirmed, two in each group. Immediate post-procedural endoleaks were detected in two and three patients in group A and B, respectively. No other major complications were found in either group, except for one retrograde type A dissection in group A. During follow-up, the initial clinical success rates were 90.24% and 92.86% in groups A and B, respectively. The primary and secondary mid-term clinical success rates were 87.5% and 90% in group A, and both of them were 92.68% in group B. Rupture-free survival and LSA patency were not significantly different between the two groups. The incidence of complete thrombosis in the aorta distal to the stent graft was 67.65% and 61.11% in groups A and B, respectively. Apart from the lower clinical success rate of fenestration technique, both physician-modified techniques are available for LSA revascularization during zone 2 TEVAR and significantly promote favorable aortic remodeling.

(413) Obturator Fenestration Technique for the Woody Indurated Penis

Abstract Introduction Performing penile implant surgery can be challenging especially in the presence of a woody indurated penis (e.g. post priapism, post infection, prolonged h/o ICI, etc.) The loss of corporal smooth muscle cells and excess of collagen deposition caused by corporal fibrosis can create challenges and increase risk of perforation, crossover and certainly infection. Clinically, these fibrotic corpora make placement of a penile prosthesis a difficult surgical procedure. Objective We demonstrate how the Obturator Fenestration Technique facilitates placement of a penile implant in the woody indurated penis. Methods 48 y/o male w/ Hx of a 3-day Priapism treated with a shunt at the time. Patient was not offered a penile implant until 8 months following event. At the time of penile implant surgery the urologist placed a malleable halfway up on the right corpora and did not attempt the other side and case was aborted. Physical examination revealed diffusely woody indurated corporeal tissue throughout the left corpora and distally on the right corpora Results Penile implant was successfully implanted using the obturator fenestration technique in the woody indurated penis in the patient with a previously failed attempt at implantation. Conclusions The use of the Obturator Fenestration Technique can help facilitate increasingly complex cases This can help reduce unnecessary complications and repeat revision surgery. However, there is a learning curve while using the Obturator Fenestration Technique and should not be performed by a novice surgeon We hope to improve our techniques and surgical approaches to improve surgical times and post-operative outcomes for the woody indurated penis Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific

Endoscopic fenestration of an enlarging giant occipital arachnoid cyst

This case demonstrates an endoscopic fenestration of an enlarging giant occipital arachnoid cyst. The patient is a 42-year-old woman presenting with headache, progressive vision loss, and nausea and vomiting. MRI demonstrates a large, nonenhancing cystic lesion in the right occipital lobe measuring up to 8.3 cm, consistent with an arachnoid cyst. This surgical video illustrates the technique for an endoscopic fenestration into the native ventricular system utilizing stereotactic MRI-guided stealth navigation. Postoperatively, the patient had full recovery with improvement of headaches and vision and was discharged on postoperative day 1 without complications. The video can be found here: https://stream.cadmore.media/r10.3171/2023.1.FOCVID22129.

Systematic Review and Meta-Analysis of Ex-Situ and In-Situ Fenestrated Stent-Grafts for Endovascular Repair of Aortic Arch Pathologies.

To gain insight into safety and efficacy of in situ and ex-situ fenestration techniques for total endovascular arch repair. The term ex-situ fenestration is referring to physician-modified stent-graft technique where fenestration is performed on a back table. Electronic search was conducted according to PRISMA (Preferred Reporting Items for Systematic review and Meta-analyses) guidelines from 2000 to 2020. The main outcomes measured were 30-day mortality, stroke, aortic-related mortality, and reintervention rates. Fifteen studies were eligible: 7 ex-situ fenestration (189 patients) and 8 in-situ fenestration (149 patients). In ex-situ group, dissection was the main pathology treated and proximal sealing zones were Z0 or 1 in 53.5% of patients. In in-situ group, dissection and aneurysm were equally represented in around 40% of cases and proximal sealing zones were Z0 or 1 in 46.5% of patients. Cumulative 30-day all-cause mortality was similar in both groups: 3.8% (95% confidence interval [CI]: 1.7%-8.2%) and 3.8% (95% CI: 1.6%-8.9%), respectively, in ex-situ and in-situ groups and stroke rate of 2.8% (95% CI: 1.1%-7%) and 5.3% (95% CI: 2.6%-10.5%). After a 11.1 ± 2.6 months mean follow-up for ex-situ and 16.7 ± 2.3 months for in-situ group, there were 5.2 and 1.4 reinterventions per 100 patients-years, respectively, for ex-situ and in situ groups. Aortic-related mortality rates of, respectively, 3.2% (95% CI: 1.3%-7.4%) and 2.6% (95% CI: 0.9%-7.3%) were noted in ex-situ and in situ groups. The reported data show favorable short-term results of both ex-situ and in-situ fenestration techniques with low mortality and strokes rates. However, durability is still questionable given the lack of long-term data. Both options may have their place in arch repair beyond the spectrum of emergent and urgent cases, on condition that results stand the test of time. In situ and ex-situ fenestration techniques have been initially developed to overcome emergency or as a bail out techniques however giving the promessing favorable short term results indications of these techniques may be extended to elective patients ineligible to customized stent-grafts and possibly in the futur to more elective cases as an option for total endovascular arch repair.

Endovascular repair of aortic pathologies involving the aortic arch using castor stent-graft combined with in-vitro fenestration technology

BackgroundAortic arch pathologies are concerning clinical conditions with poor prognoses. The use of thoracic endovascular aortic repair (TEVAR) has been investigated to treat aortic arch pathologies. Nonetheless, cerebral blood flow regulation during endovascular aortic arch repair therapy remains challenging. Castor, a unique single-branched stent graft, has been proven effective for retaining the left subclavian artery (LSA). This study aimed to determine whether endovascular therapy for pathologies involving the aortic arch using Castor in combination with the in-vitro fenestration technique is promising, effective, and safe.MethodsEligible patients were enrolled between June 2018 and December 2021. All patients underwent TEVAR with an evaluated proximal landing zone for “Castor” located in Ishimaru zones 0–1. Moreover, the supra-aortic branches (SABs) were reconstructed using the Castor in combination with the in-vitro fenestration technique.ResultsHerein, 57 patients with aortic arch lesions were treated with Castor in combination with the in-vitro fenestration technique. Innominate artery and the left carotid artery (LCA) were reconstructed in 5 patients, LCA and left subclavian artery (LSA) were reconstructed in 22 patients, and the total SABs were effectively reconstructed in 30 patients (including a hybrid arch repair case). Among them (excluding a hybrid arch repair case) were in-vitro fenestration methodologies for LCA in 32 of 34 cases (2 switched to in-situ fenestration) and LSA in 51 of 56 cases (3 switched to in-situ fenestration and 2 converted to spring coil caulking); furthermore, LCA and LSA in-vitro fenestration were simultaneously successfully performed in 27 of 34 cases. There were no surgical-related neurological complications, and early mortality was estimated at 5.26%. At a mean follow-up of 3.75 months, computed tomography (CTA) images confirmed that each branch stent remained patent. There were no signs of endoleaks, migrative manifestations, or the need for secondary endovascular intervention or conversion to open surgical procedures.ConclusionCastor, in combination with in-vitro fenestration, reflects a feasible, efficient procedure for re-developing SABs.

Imaging-Guided Percutaneous Transperitoneal Balloon Fenestration of Postrenal Transplant Lymphocele: A Case Report of Experience with New Technique

AbstractRenal transplantation is the treatment of choice for improved survival and quality of life in patients with end-stage renal disease. However, perirenal fluid collections are common surgical complications after renal transplant, with about 0.6 to 18% of patients developing a lymphocele. Conventional treatments include percutaneous aspiration and drainage, laparoscopic fenestration, and open surgical decompression stepwise. Recently, a new image-guided percutaneous transperitoneal balloon fenestration technique has been described as an alternative to the laparoscopic or surgical technique. We present the case of a 25-year-old male patient diagnosed with a lymphocele after 2 months of transplantation and no resolution of the lymphocele with percutaneous aspiration and drainage. We used this new technique under ultrasound and fluoroscopy guidance, which resulted in the resolution of the lymphocele at 1 month postprocedure. This case report highlights this new technique's potential role in successfully managing the posttransplant lymphocele in a minimally invasive manner.

Results of the in situ fenestration technique for preservation of the Left subclavian artery in the endovascular repair of acute aortic syndromes in a reference center.

The in situ fenestration (ISF) technique consists of maintaining the patency of the aortic branch after the endoprosthesis is already in place as a viable, effective, and fast-performing alternative to revascularize the aortic arch arteries. To report the experience with a series of cases of endovascular treatment of Acute Aortic Syndromes involving the aortic arch, using the ISF technique in a specialized center. We analyzed data collected from patients treated with ISF during TEVAR for Acute Aortic Syndromes involving the aortic arch from June 2020 to January 2022, assessing perioperative outcomes, including immediate and late success rates, complications, morbidity and mortality, and short and medium term aortic branch patency. Of the 11 patients eligible for the ISF procedure, 9 were successful, with a technical success rate of 81%. No patient had a type 1A endoleak related to fenestration. There was complete thrombosis of the false lumen in the thoracic aorta in 77% cases. No death was related to the fenestration technique. ISF as feasible and with a high rate of technical success and good results in the short and medium term. Prospective studies with long-term clinical follow-up are still needed to fully assess the durability of these unreinforced fenestrations.

Standardised Tendon Fenestration with ITEC-Technique for Lateral Epicondylosis with Injection of Betamethasone versus Autologous Blood.

Background: Infiltration is one of the treatment options for lateral epicondylosis, a degenerative process in the tendon of the musculus extensor carpi radialis brevis. The aim of this study was to evaluate the clinical outcome of a standardised fenestration technique, the Instant Tennis Elbow Cure (ITEC) technique, with injection of betamethasone versus autologous blood. Methods: A prospective comparative study was performed. Twenty-eight patients received an infiltration with 1 mL betamethasone, in combination with 1 mL 2% lidocaine. Twenty-eight patients received an infiltration with 2 mL autologous blood. Both infiltrations were administered using the ITEC-technique. The patients were evaluated at baseline, 6 weeks, 3 months and 6 months using Visual Analogue Scale (VAS), Patient-Rated Tennis Elbow Evaluation (PRTEE) and Nirschl staging. Results: At the 6-week follow-up, the corticosteroid group showed significantly better results for VAS. At the 3-month follow-up, no significant differences were observed for all three scores. At the 6-monthfollow-up, the autologous blood group showed significantly better results for all three scores. Conclusions: Standardised fenestration using the ITEC-technique with corticosteroid infiltration is more effective in reducing pain at the 6-week follow-up. At the 6-month follow-up, the use of autologous blood is more effective in pain reduction and functional recovery. Level of Evidence: Level II.

Ultrasound-guided A1 pulley release using fenestration technique

Ultrasound-guided A1 pulley release using fenestration technique

A Modified Transversal Two-Suture Microsurgical Intussusception Vasoepididymostomy for the Treatment of Epididymal Obstructive Azoospermia

Introduction: We have developed a modified vasoepididymostomy procedure, namely “fenestrated” transversal two-suture microsurgical intussusception vasoepididymostomy. This study aimed to investigate the therapeutic efficacy and outcome of this fenestrated vasoepididymostomy for epididymal obstructive azoospermia (OA). Methods: Microsurgical two-suture transversal intussusception vasoepididymostomy was performed using our modified fenestration technique in 64 OA patients due to epididymal obstruction at our hospital. Fenestration means making an opening on the epididymal tubule wall. The edges of the epididymal tubule “window” were stitched transversally (two stitches) using the two double-armed 9–0 atraumatic sutures. The epididymal tubule was anastomosed to the lumen of the vas deferens. The patency rate and pregnancy rate were assessed. Results: Of the 64 OA patients, 45 received bilateral microsurgical two-suture transversal intussusception vasoepididymostomy, while 19 underwent unilateral microsurgical two-suture transversal intussusception vasoepididymostomy. All of the patients were followed up after the operation. The follow-up period ranged from 4 to 54 months. Among 45 cases of bilateral surgery, the patency rate was 88.89% (40/45), and the natural pregnancy rate was 28.89% (13/45). After the patency was confirmed postoperatively, 3 cases had recurrent OA, of which 2 cases had return of sperm to the ejaculate by oral antibiotics and scrotal self-massage. As for the 19 cases of unilateral microsurgery, the patency rate was 68.42% (13/19), and the natural pregnancy rate was 21.05% (4/19). Conclusion: The fenestrated transversal two-suture microsurgical intussusception vasoepididymostomy can achieve a good patency rate in OA patients and did not increase the difficulty and duration of the procedure.

Computational study of fenestration and parallel grafts used in TEVAR of aortic arch aneurysms.

To explore the differences between fenestration technique and parallel grafts technique of thoracic endovascular aortic repair, and evaluate the risk of complications after interventional treatment of aortic arch aneurysms. A three-dimensional aortic model was established from the follow-up imaging data of patient who reconstructed the superior arch vessel by the chimney technique, which was called the chimney model. Based on the chimney model, the geometric of the reconstructed vessel was modified by virtual surgery, and the normal model, fenestration model and periscope model were established. The blood flow waveforms measured by 2D phase contrast magnetic resonance imaging were processed as the boundary conditions of the ascending aorta inlet and the superior arch vessels outlets of the normal model. The pressure waveform of descending aorta was obtained using three-element Windkessel model, and specific pressure boundary conditions were imposed at reconstructed branches for the postoperative models. Through computational fluid dynamics simulations, the hemodynamic parameters of each model were obtained. The reconstructed vessel flow rate of the periscope model and the fenestration model are 33% and 50% of that of the normal model, respectively. The pressure difference between the inner and outer walls of the fenestration stent and periscope stent is 3.15 times and 7.56 times that of the chimney stent. The velocity in the fenestration stent and periscope stent is uneven. The high relative residence time is concentrated in the region around the branch stents, which is prone to thrombosis. The "gutter" part of the chimney model may become larger due to the effect of the stent-graft DF, increasing the risk of endoleak. For patients with incomplete circle of Willis, the periscope technique to reconstruct the supra-arch vessels may affect blood perfusion. It is recommended to use balloon-expandable stent for fenestration stent and periscope stent, and self-expanding stent for chimney stent. For patients with aortic arch aneurysms, the fenestration technique may be superior to the parallel grafts technique.

Single-branched stent-graft with on-table fenestration for endovascular repair of primary retrograde type A aortic dissection: A multicenter retrospective study.

This study aims to evaluate the feasibility, efficacy, and safety of a single-branched stent-graft with on-table fenestration for primary retrograde type A aortic dissection (RTAD) during thoracic endovascular aortic repair (TEVAR). From January 2019 to December 2021, 36 patients with primary RTAD from five tertiary hospitals received medical management in the acute phase. They underwent TEVAR with a proximal zone 1 landing for aortic arch reconstruction in the subacute phase, using a fenestration technique on a single-branched stent-graft. Nearly 2 weeks after admission, computed tomography angiography (CTA) was re-examined to evaluate the thrombosis status of retrograde false lumen (FL). The primary outcomes were technical success, patency of the target branch arteries, and absence of type Ia endoleaks. The second outcomes were stent-graft-related complications and all-cause mortality. The mean age was 56.2 ± 11.3 years, and 29 (80.6%) were male. After a median interval of 18.0 [interquartile range (IQR), 17.0-20.3] days of medical treatment, the partial and complete thrombosis of proximal FL rates increased to 52.8% and 47.2%, respectively. One patient (2.8%) experienced postoperative type Ia endoleaks, and was successfully re-treated using coli and Onyx glue. The median hospital stay was 20.5 (IQR, 18.0-23.0) days. The overall technical success rate was 100%. The median follow-up time was 31.5 (IQR, 29.8-34.0) months. There was one death (2.8%) due to gastrointestinal bleeding. Distal aortic segmental enlargement (DASE) occurred in two (5.6%) patients. No major complications or recurrent dissections in the proximal landing zone were recorded during follow up. The retrograde FL in primary RTAD could realize partial or complete thrombosis after medical management in the acute phase, and it might be regarded as a valid proximal landing zone for endovascular repair. The single-branched stent graft with on-table fenestration performed in the subacute phase may be feasible strategy in selective primary RTAD patients.

Trans–Rotator Cuff Approach for Spinoglenoid Cysts: Tips and Traps

In this study, we introduce an arthroscopic technique for posterior-superior capsular fenestration and spinoglenoid cyst resection completely via a trans–rotator cuff approach. This approach can provide a full field of view and allow evaluation of the scope of the cyst under direct vision, which reduces the risk of recurrence and injury to the suprascapular neurovascular bundle.

Endovascular Management of Aortic Arch Diseases: Current Status and Future Trends

Treatment of aortic arch (AA) diseases is challenging for surgeons. Conventional open surgery remains the “gold standard” but is associated with significant morbidity and mortality despite improvements in techniques. In the last 2 decades, thoracic endovascular aortic repair (TEVAR) has become the first-line treatment for diseases of the descending aorta, and its indications have expanded gradually. Various strategies have been proposed to preserve supra-aortic branches in TEVAR: hybrid technique, chimney technique, fenestration technique (including custom-made fenestrated or “scalloped” stent grafts, in situ fenestration, and physician-modified fenestration), and branched stent grafts. Though acceptable outcomes of endovascular aortic repair have been documented, the evidence regarding its long-term safety and efficacy is lacking, and concerns remain about the risk of cerebrovascular events, retrograde type-A dissection, endoleaks, and branch occlusion. This review discusses the current status and progress of endovascular repair of the AA, and looks toward future trends. We believe that multidisciplinary collaboration of a “HENDO” team (professionals in hybrid repair, endovascular repair, open surgery, cardiovascular anesthesia, and genetics) is essential for future repair of the AA to provide the optimal treatment.

Emergent In Situ Fenestration in the Ascending Aorta for the Endovascular Repair of a Large Pseudoaneurysm: A Technical Note

Purpose: The purpose of this article is to describe an emergent in situ fenestration (ISF) technique in the ascending aorta for the endovascular repair of a large pseudoaneurysm using a trans-septal needle device through direct right common carotid artery access, in a patient with left ventricular assist device (LVAD). Technique: We performed, in a multidisciplinary team-work approach, an emergent ISF to correct the displacement of a physician-modified thoracic endograft released in the ascending aorta to correct a large anastomotic pseudoaneurysm in a patient who underwent ascending aorta replacement and subsequent LVAD implantation. We used a trans-septal needle device inserted through a direct access to the right carotid artery and performed an ISF to restore the patency of the outflow ostium of the LVAD. Window was then completed and stabilized with a nitinol balloon expandable covered stent graft obtaining an effective exclusion of the anastomotic aortic aneurism and the regular patency of the LVAD outflow graft with no signs of leaks. Conclusions: Multidisciplinary teamwork approach can be crucial in challenging procedures where an alternative approach may lead to problem solving. The ISF technique may be a valid option to adopt in emergency cases in which no other technical solutions are suitable. Clinical Impact The endovascular approach has become more and more frequent for the treatment of vascular pathologies, getting increasingly refined and complex. Thereby the chance of incurring intraprocedural troubles has grown and bailout strategies should always be present. In situ fenestration is a technique to be aware of and that could help you recover from difficult situations. We report a possible rescue maneuver that can be applied also in arduous anatomies such as the ascending aorta. Moreover, we would like to highlight the importance of a multidisciplinary working environment that can enrich our everyday practice accomplishing effective and unexpected solutions.