iCast Stent Research Articles

Revascularization of the Left Subclavian Artery during TEVAR Utilizing a Percutaneous In-Situ Technique

Background: We report the use of retrograde in situ laser-assisted endograft fenestration during thoracic endovascular aortic repair. Methods: A 69-year-old man presented with a pseudoaneurysm just distal to the left subclavian artery. Ten years previously he was involved in a motor vehicle accident. He was complaining of chest pain and left shoulder pain. During the workup of acute coronary syndrome, a peripherally calcified pseudoaneurysm measuring up to 3.9 cm involving the posteromedial aspect of the distal aortic arch was identified (Fig 1). Old fractures of the pubic rami, left ribs, and left clavicle were also identified compatible with prior chest trauma. Results: Endovascular thoracic aneurysm repair was elected with revascularization of the left subclavian artery. The patient had a dominant left vertebral and also was left hand-dominant. Because of the clavicular fracture and multiple rib fractures on the left, in situ stent graft fenestration was performed rather than carotid subclavian bypass to avoid the area of previous trauma. The proximal and distal neck landing zones measured 31 mm in diameter. The proximal neck length was only 10 mm distal to the left subclavian artery, necessitating coverage. A 36-mm Talent (Medtronic, Santa Rosa, Calif) thoracic stent graft was deployed, with the covered portion extending to the left carotid artery with the Free-Flo spring over the left carotid artery. A 2.3-mm Turbo excimer laser (Spectranetics, Colorado Springs, Colo) was advanced through a 7F sheath from a left brachial approach and used to fenestrate the stent graft under fluoroscopic guidance. The fenestration was dilated and stented with an 8 × 38 mm iCast stent (Atrium, Hudson, NH; Fig 2). The stent was flared proximally and distally for seal. The patient tolerated the procedure well and was discharged home on the second postoperative day. There was no pressure gradient between the upper extremities on follow-up evaluation, with the aneurysm being completely excluded with a widely patent left subclavian stent (Fig 3, Fig 4). The patient's left chest and shoulder pain completely resolved.Fig 3The aneurysm being completely excluded with a widely patent left subclavian stent.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 4The aneurysm was completely excluded with a widely patent left subclavian stent.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Conclusions: In situ fenestration using the excimer laser allows for rapid branch management of the aortic arch vessels and minimizes the need for surgical reconstructions. Furthermore, this technique may be helpful as a bailout maneuver for a misplaced endograft. The long-term durability of this procedure is unknown and requires further study.

Endovascular Repair of Acute Traumatic Thoracic Aortic Transection With Laser-Assisted In-Situ Fenestration of a Stent-Graft Covering the Left Subclavian Artery

To report the use of in-situ laser-assisted endograft fenestration during thoracic endovascular aortic repair (TEVAR). A healthy 26-year-old man presented to the emergency department after sustaining blunt chest trauma. He was hemodynamically stable, although he subjectively complained of tearing chest pain and pleuritic chest wall pain. Radiography revealed a left clavicular fracture, multiple rib fractures, and a widened mediastinum. Imaging showed a partially contained acute aortic transection just distal to the takeoff of the left subclavian artery (LSA); the arch had a bovine configuration, with a shared origin of the right innominate and left common carotid arteries. Endovascular repair was elected, but to avoid sacrificing the LSA, TEVAR with in-situ graft fenestration was performed to reduce the risk of posterior circulation stroke, spinal cord ischemia, and subclavian steal syndrome. A Talent thoracic stent-graft was deployed, with the covered portion of the endograft extending just distal to the shared origin of the innominate and left carotid arteries. A laser catheter was advanced through the LSA to fenestrate the endograft; the fenestration was dilated and stented with an iCast stent, which was flared proximally and distally to effect a seal. At 6 weeks, imaging documented that the repair was patent and secure; the patient continues to do well at his most recent follow-up at 8 months. This technique may provide a means for extending thoracic endografting technology to a greater number of patients with acute thoracic aortic pathology.