Early and midterm outcomes of in situ laser fenestration during thoracic endovascular aortic repair for acute and subacute aortic arch diseases and analysis of its complications

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

INTRODUCTION

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.

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

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.

Early and Midterm Outcomes of Endovascular Aortic Arch Repair Using In Situ Laser Fenestration

INTRODUCTION

The aim of this study is to present single-center outcomes in patients treated with in situ laser fenestration thoracic endovascular aortic repair (LFTEVAR) for various aortic arch pathologies and assess the impact of increasing experience.

METHODS

The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement was followed. A retrospective analysis of prospectively collected single aortic center data was conducted, including baseline information and peri- and post-operative outcomes of consecutive patients managed with LFTEVAR for aortic arch pathologies. Patients were enrolled from April 1, 2017 to January 31, 2023. The cohort was dichotomized to compare early (2017-2019) and late experience (2020-2023). Primary outcomes were peri-operative mortality and cerebrovascular morbidity.

RESULTS

Thirty patients were included (63.3% males, mean age 69.8±9.6 years); 21.4% presented with aortic ruptures. Aortic aneurysm involving the aortic arch was the most frequent pathology (53.3%). Forty target vessels (TVs) were revascularized, including 19 left subclavian arteries (47.5%) and 17 left common carotid arteries (42.5%). Double fenestrations were performed in 10 patients. The proximal landing zone was Ishimaru zone 0 in 5 patients (16.7%) and zone 1 in 13 patients (43.3%). Technical success was 93%. No spinal cord ischemia was recorded, and 3 patients (10%) suffered a post-operative stroke, of which 1 was major (3.3%). The median follow-up was 12 months (range=1-48 months). Thirty-day and follow-up mortality rates were 13.5% and 15.3%, respectively. Target vessel instability was 10%, of which 3.8% required reintervention. There was no statistically significant difference in outcomes between the early and late experience groups.

CONCLUSIONS

Laser fenestration thoracic endovascular aortic repair of the aortic arch performed in experienced aortic centers is associated with low early mortality and stroke rates. It is a safe and effective therapeutic option in patients considered unfit for open repair.

CLINICAL IMPACT

Custom-made devices for arch pathologies requiring urgent repair are not an option because of manufacturing delays. Off-the-shelf devices with single branch arch prostheses, and outside IFU techniques such as parallel-grafts and surgeon-modified endografts have been proposed in this setting. Another off-the-shelf alternative is in situ laser fenestration thoracic endovascular repair (LFTEVAR), which addresses many limitations of the other off-the-shelf options. Our study reports the outcomes of 30 patients treated with LFTEVAR, showing that it is a viable therapeutic option in patients considered unfit for open repair acknowledging that sufficient experience with complex endovascular aortic repair is mandatory to achieve acceptable outcomes in these high-risk patients with challenging aortic anatomies.

Outcomes of Castor Single-Branched Stent Graft for Reconstruction of Multiple Supra-Aortic Branches in Aortic Arch Disease

PURPOSE

To report the outcomes of a combination of Castor single-branched stent grafts with other techniques for the reconstruction of multiple supra-aortic branches in aortic arch disease.

MATERIALS AND METHODS

Between December 2019 and December 2021, 20 patients with aortic arch disease underwent thoracic endovascular aortic repair (TEVAR) at our institution using a Castor single-branched stent graft combined with the fenestration, chimney, or bypass techniques. Thoracic endovascular aortic repair is indicated for complicated or acute type B aortic dissection (TBAD), nonruptured aneurysms with a maximum aneurysm diameter >5.5 cm or showing rapidly expanded, ruptured, or threatened aneurysms, and penetrating aortic ulcers (PAUs) with a maximal aortic diameter >5.5 cm or with PAUs >10 mm deep or >20 mm in diameter. Preoperative, intraoperative, and postoperative clinical data were recorded.

RESULTS

The median age of the patients was 56 (range=52-69 years) years, and 19 patients were men. Seven patients underwent the Castor single-branched stent graft and left common carotid artery (LCCA) chimney technique, 8 patients underwent the Castor single-branched stent graft and fenestration technique, and 5 patients underwent the Castor single-branched stent graft and bypass technique. The technical success rate was 100%. Major adverse events included 2 endoleaks, 1 spinal cord ischemia, and 1 early-stage retrograde type A aortic dissection. No cerebral stroke-related complications were observed. The mortality rate was 10% (2/20 patients). One patient with thoracic aortic aneurysm (TAA) died because of a sudden decrease in oxygen saturation and blood pressure after surgery. Relatives declined autopsy, and the cause of death was not determined. Another patient died of a retrograde type A dissection after surgery. The median follow-up period was 6 months (range=3.5-12 months). During follow-up, 1 patient with type I endoleak underwent thoracotomy again after a year. The remaining patients recovered well.

CONCLUSIONS

The combination of a Castor single-branched stent graft with fenestration, chimney, or bypass techniques may be an effective treatment for preserving multiple supra-aortic branches in aortic arch disease.

CLINICAL IMPACT

This study introduced three methods of reconstruction of multiple supra-aortic branches using a Castor single-branched stent graft (Castor single-branched stent graft combined with fenestration, chimney, or bypass technique) and analysed their advantages and shortcomings to provide experience for the future treatment of aortic arch diseases.

Comparison of Chimney and Fenestrated Techniques for Supra-Aortic Branch Revascularization During Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis

PURPOSE

To compare the technical and clinical outcomes of fenestrated thoracic endovascular aortic repair (F-TEVAR) and chimney thoracic endovascular aortic repair (CH-EVAR) of aortic disease.

METHODS

PubMed, Embase and Cochrane databases were systematically searched to identify studies on the management of thoracic aortic pathologies using chimney or fenestrated techniques published between 2000 and 2022. Individual studies provided at least one of the following essential outcomes: technical success, immediate and follow-up type I endoleak, 30-day and aorta-related mortality, cerebral events and supra-aortic branch patency.

RESULTS

24 chimney (1106 patients) and 21 fenestrated technique studies (1040 patients) were included. The scope of the study encompassed various thoracic aortic conditions, such as thoracic aortic dissection, thoracic aortic aneurysm, thoracic aortic ulcer, and other thoracic aortic diseases. Technical success was defined as the handling of the principal ailment affecting the aorta, devoid of any instances of complications. The technical success rates were higher in fenestrated group compared with chimney group (98.0% vs. 95.8% p < 0.001), and the rate of type I endoleak either immediately or during follow-up was higher in the chimney technique group (9.3% vs. 1.3% p < 0.001, 4.0% vs. 0.0% p < 0.001). The chimney technique group had higher 30-day mortality and aorta-related mortality than those in the fenestrated technique group (2.1% vs. 0.3% p < 0.001, 0.4% vs. 0.0% p < 0.001). Morbidity rates of cerebral events and supra-aortic branch patency were same in both groups (2.2% vs. 1.1% p = 0.116, 98.2% vs. 99.4% p = 0.094). The chimney technique group had longer operative time (110.0 min vs. 90.8 min p < 0.001). Two groups had same fluoroscopy time (34.0 min vs. 33.4 min p = 0.614).

CONCLUSIONS

The finding suggest that both the chimney and fenestrated techniques are efficacious in supra-aortic branch reconstruction. However, the fenestrated technique exhibits potential superiority as an interventional strategy, as it demonstrates a lower incidence of type 1 Endoleak, 30-day mortality, and aorta-related death following TEVAR.

Expert opinion: How to treat type IA endoleakage

Type Ia endoleaks due to failed sealing or loss of landing zone and the adequate management thereof remain crucial for long-term therapeutic success following TEVAR. This expert opinion summarizes our institutional experience with endovascular, open surgical, and hybrid techniques in the context of recent scientific publications. The rapid turnover of technical innovations, but most importantly outcome data demonstrate the requirement for increasingly patient-tailored treatment strategies and the need for specialized aortic centers. The latter should offer a complete range of treatment options, an adequate perioperative management, and the highest level of multidisciplinary expertise.

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

OBJECTIVES

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).

METHODS

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.

RESULTS

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 ± 14.4 months, 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 5 months 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.

CONCLUSION

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.

Laser Fenestration in TEVAR - Perspectives and Future Directions

Endovascular aortic repair has been increasingly utilized to treat a multitude of thoracic aortic pathologies. When placement of a thoracic endograft necessitates coverage of one or more of the great vessels, in situ laser fenestration is a safe and effective option for supra-aortic trunk revascularization. Certain anatomic factors may render laser fenestration more technically challenging, particularly depending on aortic arch type and branch vessel characteristics. Short-term and mid-term outcomes have shown promising results for mortality, stroke, and complication rates. Future developments may extend the utility of this approach and allow it to be applied to a more widespread set of patients with challenging anatomy.

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

Background

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).

Methods

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.

Results

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.

Conclusions

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.

Single branched endografts for the preservation of left subclavian artery in the treatment of zone II thoracic aortic lesions a systematic review and meta-analysis

BACKGROUND

We investigated the safety and feasibility of single branched endografts in the treatment of zone II thoracic endovascular aortic repair (TEVAR).

METHODS

We performed a systematic research on Medline, Scopus and EMBASE for articles published up to February 2023. Primary endpoints included technical success, thirty-day mortality, stroke and spinal cord injury (SCI) as well as unassisted left subclavian artery (LSA) branch patency by the end of follow-up. Secondary endpoints included early thirty-day and persistent endoleaks, new onset dissection and reintervention by the end of follow-up.

RESULTS

Fourteen studies, three prospective case series and eleven retrospective case series comprised of 727 patients were finally included. The pooled technical success and thirty-day mortality rates were 94.86 % (95% CI: 90.95-97.86) and 0.14% (95% CI: 0.00-0.87). The thirty-day stroke and SCI rates were 0.45% (95% CI: 0.00-1.39) and 0.08% (95% CI: 0.00-0.99) respectively, while the unassisted LSA branch patency estimate was 99.12% (95% CI: 97.97-99.86). The early thirty-day and persistent endoleak rates were 5.19% (95% CI: 2.45-8.65) and 2.57% (95% CI: 0.36-6.02), whereas new onset dissections and reinterventions estimates were 0.94% (95% CI: 0.17-2.11) and 2.40% (95% CI: 0.41-5.42).

CONCLUSION

While we have displayed the safety and feasibility of single branched endografts in the treatment of zone II thoracic aortic lesions, physicians should be aware of the persistency displayed by early type I endoleaks eventually requiring re-intervention. The variations in device and lesion characteristics accompanied by the short-term follow-up presented in our review do not allow for definite conclusions to be drawn, necessitating further research through high-quality randomized controlled trials.

Long-term outcomes of thoracic endovascular repair with quick fenestrater assisted in situ fenestration for type B aortic dissection

OBJECTIVES

To report the long-term outcomes of patients with type B aortic dissection (TBAD) treated with thoracic endovascular aortic repair (TEVAR) and quick fenestrated (QF)-assisted in situ fenestration (ISF).

METHODS

Between October 2017 and December 2018, 15 patients with TBAD requiring revascularization of the supra-aortic trunks underwent TEVAR with QF-assisted ISF at our institution.

RESULTS

Thirteen of the 15 patients were male, and the mean age was 52.87 ± 11.26. The technical success rate was 100%. Thirty-day mortality rate was 0. The median follow-up period was 41 months (range, 35-49). During follow-up, one non-aortic-related death was recorded, no fenestration lost its alignment, and no stroke or stent graft migration was observed. Two patients underwent another successful endovascular repair. One case of type Ib endoleak occurred 19 months postoperatively. This was caused by aortic progression distal to the stent graft. Another stent graft with a larger diameter was implanted in the descending aorta. One case of type Ic endoleak was observed 35 months postoperatively. The patient was diagnosed during the annual follow-up without any symptoms. Another bridging stent graft was implanted into the left subclavian artery distal to the already existing one, and the type Ic endoleak was successfully treated.

CONCLUSIONS

TEVAR with QF-assisted ISF may be an effective treatment for ISF in type B aortic dissection.

A Systematic Review of Contemporary Outcomes from Aortic Arch In Situ Laser Fenestration During Thoracic Endovascular Aortic Repair

BACKGROUND

In situ laser fenestrated endovascular aortic repair (L-FEVAR) is a novel and creative solution for complex aortic pathologies in the urgent and emergency setting. Outcomes of this technique, however, are poorly reported. We sought to evaluate the efficacy, safety, and outcomes of L-FEVAR in aortic arch pathologies.

METHODS

A systematic literature review and analysis were conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses and Cochrane guidelines. A search was conducted using Google, PubMed, and Scopus to identify studies evaluating L-FEVAR. Two independent reviewers determined study inclusion. Case reports and series including < 10 patients were excluded. Reviewers also assessed the methodological quality and extracted data regarding outcomes. A meta-analysis of endoleak event rates was conducted using a fixed-effect model due to small sample size.

RESULTS

Eight studies met inclusion criteria between 2013 and 2021. Most studies were retrospective (87.5%) with median follow-up duration of 12.5 months (range 10-42). There were 440 patients included (range 15-148), mostly men (64%). Mean age was 61 years (range 53-68). Included patients were all symptomatic with L-FEVAR being technically successful in 93.3% of cases. The main indication for aortic arch intervention was aortic dissection. Single fenestrations occurred most frequently (68%), followed by triple (22%) then double fenestrations (9%). Meta-analysis of 8 studies (n = 440) demonstrated an endoleak event rate of 0.06 (95% confidence interval 0.04-0.09, P < 0.001) with no observed statistically significant heterogeneity of effects (Q = 7.91, P = 0.34). The median operative time was 162 min (range 53-252) with median length of stay of 10 days (range 7-17). Primary branch patency was 96.6%. Secondary patency rate was 97%. Pooled complication rates such as endoleak occurred in 4.8%, stroke in 2.0%, spinal cord ischemia in 0.2%, retrograde dissection in 0.9%, and 30-day death in 2.0%. Access complications occurred in 0.4%. Antiplatelet regimen was poorly reported in the study cohort.

CONCLUSIONS

In situ laser fenestration is a feasible, safe, and effective approach to treat aortic arch disease in patients who are unsuitable for open or custom-made endovascular means. High technical success and excellent short-term branch patency can be achieved. These single-institution series exhibit promising short-term outcomes. In a similar paradigm to investigational device exemptions studies for custom-made and physician modified endografts, these preliminary data make a persuasive argument for larger long-term multi-institutional prospective study of this promising technique.

Systematic Review on In Situ Laser Fenestrated Repair for the Endovascular Management of Aortic Arch Pathologies

Background: In situ laser-fenestrated thoracic aortic endovascular repair (FTEVAR) has emerged as a valuable alternative for aortic arch management. This review assessed the early and follow-up outcomes of in situ laser-FTEVAR in aortic arch pathologies. Methods: The PRISMA statement was followed. The English literature was searched, via Ovid, until 15 October 2022. Observational studies, published after 2000, reporting on early and follow-up outcomes for the in situ laser-FTEVAR were eligible. The Newcastle–Ottawa Scale was used to assess the risk of bias. Primary outcomes were the technical success, stroke, and mortality at 30-days, and the secondary were the mortality and reintervention during follow-up. Results: Six retrospective studies from 591 and 247 patients were included. Fifty-nine (23.9%) patients were managed for aortic arch aneurysms and 146 (59.1%) for dissections; 22.6% of them for type A. Technical success was at 98% (range 90–100%). Eight patients died (3.2%) and 11 cases presented any type of stroke (4.5%) during the 30-day follow-up. The mean follow-up was 15 months (1–40 months). Ten deaths were reported (4.2%); one was aortic-related (10%). Thirteen re-interventions (6.0%) were performed. Conclusions: In situ laser-FTEVAR for aortic arch repair may be performed with high technical success and low 30-day and midterm follow-up mortality, stroke, and re-intervention rates when applied in well selected patients and performed by experienced teams.

Meta-analysis and meta-regression of the total endovascular aortic repair in aortic arch

Background: The total endovascular repair of the aortic arch is becoming more and more an acceptable alternative to the open repair in selected patients. The aim of the present study is to perform a meta-analysis of the available data on the outcomes of the various endovascular techniques used to treat the pathologies in this challenging anatomical area. Patients and methods: An extensive electronic search in PubMed/MEDLINE, Science Direct Databases, and the Cochrane Library was conducted. All papers published up to January 2022 on the endovascular techniques in the aortic arch (chimney-thoracic endovascular aortic repair (ChTEVAR), fenestrated/branched grafts as custom made devices (CMD) and surgeon modified TEVAR (SM TEVAR) providing information about at least one of the essential outcomes defined in the inclusion criteria. Results: Out of the 5078 studies found through the search in the databases and registers, 26 studies with a total number of patients of 2327 with 3497 target vessels were included in the analysis. The studies reported a high technical success rate with an estimated proportion of 95.8% (95% CI, 93-97.6%). Moreover, the pooled estimation of the early type Ia/III endoleak was 8.1% (95% CI, 5.4-12.1%). The pooled mortality was 4.6% (95 CI, 3.2-6.6%) with a significant heterogeneity and the stroke had an estimated proportion (major and minor combined) of 4.8% (95% CI, 3.5-6.6%). A meta-regression analysis showed no significant variation between the groups in mortality (P=.324) showed however a significant difference between the therapeutic methods regarding stroke P<.001 (lower rate in ChTEVAR and SM vs. CMD). Conclusions: The present meta-analysis could demonstrate good short- and long-term outcomes of the multiple total endovascular repair methods used in the aortic arch.

Physician-Modified Stent Graft for Blunt Thoracic Aortic Injuries: Do the Benefits Worth the Trouble?

BACKGROUND

Obtaining a suitable proximal landing zone in blunt thoracic aortic injuries (BTAI) often necessitates coverage of the left subclavian artery (LSA). This study aimed to evaluate the outcomes of physician-modified endovascular grafts (PMEGs) in this indication.

METHODS

We performed a retrospective analysis of a prospective registry including all patients who had undergone a thoracic endovascular aortic repair (TEVAR) for BTAI from October 2008 to October 2020. Starting in 2015, patients requiring coverage of the LSA were either treated using a physician-modified proximal scalloped or single-fenestrated stent graft. After an early postoperative computed tomography scan, follow-up was performed at 3 months, 6-months, and yearly.

RESULTS

Among 58 patients treated with TEVAR for BTAI, 23 (39.6%) patients required a zone 2 landing zone of which 10 (17.2%) patients were treated with PMEGs. The median age was 48 [31-64.5] years, and 78.2% (n = 18) patients were male. The median Injury Severity Score was 38 [27-55.5]. Coverage of the LSA was performed in 25.8% (n = 15) of the total population in which 5 patients had an LSA transposition. The median modification time was 18 [14-27] minutes. Technical success of PMEGs was 90.0% overall and 100% for fenestrated stent grafts. No stroke, paraplegia, or retrograde dissection was observed. The primary patency of the LSA in the PMEGs group was 90 % at 1 year and 28.8 % in the LSA coverage group (P < 0.01).

CONCLUSIONS

The use of PMEGs is feasible and effective in the management of BTAI with a short proximal landing zone. Further evaluation of long-term outcomes and durability are awaited.

Novel Approach to treating a COVID-19 positive patient with a Complex Arch and Descending Aneurysm and Dissection in whom open surgery is prohibitive

Ascending aortic and arch aneurysms are a challenging group of pathologies for surgeons. These typically require a complex open repair, including hypothermic circulatory arrest and carry a high peri-operative risk. Outcomes are best when performed in centers with significant experience and expertise. Many patients, because of co-morbidities, are at a prohibitive risk for these open surgeries. Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment of most acute descending thoracic aortic pathologies.[1] However, these require strict anatomic criteria to be successful and are usually confined to the distal arch and descending thoracic aorta. There are no commercially available endovascular devices in the United States to treat this patient population with ascending or proximal arch aneurysms or dissections, especially in an urgent or emergent setting, whose anatomy does not meet criteria for standard TEVAR. We present a novel endovascular approach, including a cerebral protection strategy, to treat a complex arch aneurysm and dissection in a patient who was not a candidate for an open repair.

In Situ Fenestrated Thoracic Endovascular Repair Using the Upstream Peripheral Go BackTM Re-Entry Catheter

PURPOSE

The aim is to present a case of in situ fenestrated thoracic endovascular repair, using a re-entry peripheral catheter, needing urgent repair due to recurrent episodes of hemoptysis because of an aorto-bronchial fistula after previous thoracic endovascular aortic repair (TEVAR).

TECHNIQUE

A 74-year-old male with a previous TEVAR presented with hemoptysis, fever, and cachexia. An aorto-bronchial fistula and type Ia endoleak were depicted on computed tomography angiography (CTA). Due to the patient's frail general condition, a proximal TEVAR extension was planned, prior to thoracotomy for debridement, and long-term antibiotics. An in situ fenestrated TEVAR was performed to provide proximal sealing and revascularize the left common carotid and subclavian arteries. For fenestration creation, an Upstream Peripheral Go Back catheter (Bentley, Hechingen, Germany) was used. The Go Back catheter has been approved as a re-entry tool for complex peripheral arterial revascularization. In this case, both fenestrations were successfully created. Proximal seal and target vessel patency were confirmed on CTA. Thoracotomy confirmed aortic exclusion. A wedge lobectomy was performed in combination with pediculated omentectomy to exclude the exposed endograft.

CONCLUSION

In urgent cases, where custom-made thoracic devices are unavailable, in situ fenestrations with the Go Back catheter are an alternative to laser fenestrations.

CLINICAL IMPACT

Fenestrations are often required in acute TEVAR to achieve a proximal seal in the arch. In situ fenestrations with the Go Back catheter are an alternative to laser fenestrations and PMEGs in this setting.

Technical details of thoracic endovascular aortic repair with fenestrations for thoracic aortic pathologies involving the aortic arch: A Chinese expert consensus

Thoracic aortic pathologies involving the aortic arch are a great challenge for vascular surgeons. Maintaining the patency of supra-aortic branches while excluding the aortic lesion remains difficult. Thoracic EndoVascular Aortic Repair (TEVAR) with fenestrations provides a feasible and effective approach for this type of disease. The devices needed in the procedure are off-the-shelf, with promising results reported in many medical centers. Up until now, there have been no guidelines focusing exclusively on the details of the TEVAR technique with fenestrations. Experts from China have discussed the technical parts of both in situ fenestrations (needle and laser) and fenestrations in vitro (direction inversion strategy and guidewire-assisted strategy), providing a technical reference to standardize the procedure and improve its results.

Type 1A Endoleak after TEVAR in the Aortic Arch: A Review of the Literature

Aortic arch repair is a challenging intervention. Open surgical repair is still considered the gold standard, but in high-risk patients, it is not always a reasonable option, making endovascular approaches an enticing, when not the only available, alternative for treatment. The strategies more commonly adopted are surgical supra-aortic trunk (SAT) rerouting followed by deployment of a standard thoracic endoprosthesis, chimney techniques, custom-made scalloped, fenestrated, and branched devices, and in situ or physician-modified fenestrations. If we excluded techniques involving SAT rerouting where the arch anatomy is surgically modified in order to make deployment in the aortic arch of a standard thoracic endoprosthesis possible, in the other techniques, one or more SATs are incorporated in the thoracic endoprosthesis. In these cases, no matter what solution is adopted, because of the morphology of the aorta at this level, achieving an ideal sealing is extremely difficult, and endovascular treatments of the arch are burdened by an increased risk of type IA endoleaks. PubMed, EMBASE, and Cochrane Library were searched. We identified 1277 records. After reading titles, abstracts, and full texts, we excluded 1231 records. Exclusion criteria were low-quality evidence, abstracts, case reports, conference presentations, reviews, editorials, and expert opinions. A total of 48 studies were included, for a total of 3114 patients. A type IA endoleak occurred in 248 patients (7.7%) with a mean incidence of 18.8% in chimney procedures, 4.8% and 3%, respectively, in fenestrated and branched devices, and 2.2% in in situ fenestration. We excluded from our analysis scalloped technology that is used when the target vessel originates from a healthy landing zone and represents a different anatomical setting. Type IA endoleaks are a concern with all types of endovascular aortic arch repair, and they can compromise the outcomes of the procedure. The rate of type IA endoleaks appears to be significantly higher in chimney procedures. In order to maximize sealing, whenever possible, endovascular repair of the arch should be achieved with custom-made fenestrated devices. However, chimney configurations are still a valuable solution particularly in the emergency setting, although in such a procedure, to guarantee accurate postoperative management and follow-up, an imaging protocol could be useful.

Homemade fenestrated physician-modified stent-grafts for arch aortic degenerative aneurysms

OBJECTIVE

To evaluate early and medium-term outcomes of single and double fenestrated physician-modified endovascular grafts (PMEGs) for total endovascular degenerative aortic arch aneurysm repair.

METHODS

This single-center retrospective analysis of prospectively collected data included 52 patients, from August 2013 through January 2021, undergoing home-made fenestrated thoracic endovascular aortic repair (TEVAR) for degenerative aortic aneurysms. In all cases a distal smaller fenestration for the left subclavian artery (LSA) was fashioned and the only one stented. For double-fenestrated endograft a proximal larger fenestration that incorporated both the brachiocephalic trunk and left common carotid artery was added.

RESULTS

52 patients with degenerative aortic arch aneurysms were treated. There were 36 men and the mean age was 75 ± 8 years. 31% treated with a single LSA fenestration, while 69% had a double-fenestrated TEVAR. 10% (n=5) were emergent procedures. Technical success was 100%. The median time requirement for stent graft modification was 22 ± 6 minutes. Thirty-day mortality was 2% (n=1). 5 patients (10%) had a cerebrovascular event including 2 transient ischemic attack, one minor stroke with full neurological recovery and 2 with sequelae. 2 patients (4%) experienced perioperative retrograde dissection during follow-up. No patient had a type I, type III or type II endoleak from the LSA. No patient required re-intervention. All supra-aortic trunks were patent. During a mean follow up of 18 ± 11 months, there were no conversion to open surgical repair, aortic rupture or paraplegia.

CONCLUSIONS

Single or double PMEG is a safe and suitable tool for the treatment of high morbidity pathology such as aortic arch degenerative aneurysm repair. This device can be used in elective and emergency patients.

Mid-term Comparison of One-Piece Branched Stent-Graft and Chimney Technique Treating Aortic Arch Pathologies

PURPOSE

We compared the mid-term outcomes of a one-piece branched stent-graft with the chimney technique in the treatment of aortic arch pathologies.

METHODS

Between August 2012 and December 2017, a retrospective analysis of 279 patients with thoracic aortic dissection (TAD) or aneurysm (TAA) who underwent thoracic endovascular aortic repair with b-TEVAR (n = 69, 58 TAD and 11 TAA) or c-TEVAR (n = 210, 151 TAD and 59 TAA) was performed.

RESULTS

Forty-five double-chimney for the left subclavian artery (LSA) and left common carotid artery LCCA and 165 single-chimney for the LSA were performed in chimney-TEVAR (c-TEVAR) and 69 branched-TEVAR (b-TEVAR) with 36 single-branched stent-grafts and 33 branched stent-grafts combined with fenestration technique. The c-TEVAR group experienced more in-hospital complications than the b-TEVAR group (19.5 vs. 7.2%, p = 0.017), primarily because the c-TEVAR group experienced more in-hospital cerebral ischemia events (6.2 vs. 0%, p = 0.043) and intra-operative type I endoleaks (31.9 vs. 5.8%, p < 0.01). There were significantly more follow-up type I endoleaks (21.9 vs. 4.3%, p = 0.002), cerebral ischemia events (11.0 vs. 2.9%, p = 0.042), and re-interventions (12.9 vs. 4.3%, p = 0.048) in the c-TEVAR group than in the b-TEVAR group. However, follow-up mortality was not significantly different between the c-TEVAR and b-TEVAR groups (5.2 vs. 2.9%, p = 0.638).

CONCLUSION

In patients with aortic pathologies involving the arch branches, customized b-TEVAR may result in fewer cerebral ischemia events and endoleaks than c-TEVAR. However, c-TEVAR should be considered an off-the-shelf treatment option for patients in need of emergency treatment.

LEVEL OF EVIDENCE

Level 4, Case Series.

Early experience with the Bolton Relay Pro/Plus for physician-modified fenestrated TEVAR

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) can be challenging in cases involving the aortic arch and the visceral segment. We report our initial experience with fenestrated TEVAR (f-TEVAR) for thoracic aortic disease involving aortic branches using physician-modified stent grafts (PMSGs).

MATERIALS AND METHODS

Between February 2019 and November 2020 nine patients were treated with a PMSG. Indication to treatment were a symptomatic acute type B aortic dissection (TBAD) in three cases, a penetrating aortic ulcer in three cases (two in zone 3 and one in zone 6), one case of an endoleak type I A after TEVAR, a chronic TBAD after TEVAR in one case and one case of a contained rupture of a thoracoabdominal aneurysm in zone 3. Pre-, intra- and postoperative clinical data were recorded.

RESULTS

The median patient age was 65 (IQR 60.5-71) years, and 8 (89%) patients were men. Nine stent grafts (six Bolton Relay Plus and three Bolton Relay Pro, Terumo Aortic, Vascutek Ltd., Inchinnan, United Kingdom) were deployed. Small fenestrations (8 mm) were created on table, median duration for on table stent graft modifications was 20 minutes (13-22). The technical success rate was 100%. Median operative time was 188 (116-252) minutes. No major adverse events of any sort occurred during the first 30-day postoperatively. There were no type I or type III endoleaks at the end of the procedure, and no cases of spinal cord ischemia. Two access related complications occurred (22%). After a median of 12 (range 5-12) months all patients survived and all target vessels remained patent with one case of fenestration-related type I endoleak, which required open conversion.

CONCLUSIONS

The results of our initial experience with f-TEVAR using PMSGs with the Bolton Relay stentgraft for the treatment of aortic diseases are acceptable. These results should be confirmed on larger patient cohorts.

Midterm Outcomes of an Adjustable Puncture Device for In Situ Fenestration During Thoracic Endovascular Aortic Repair

OBJECTIVE

To evaluate the midterm outcomes of in situ fenestration (ISF) with an adjustable puncture device for aortic arch branch preservation during thoracic endovascular aortic repair (TEVAR).

METHODS

From October 2016 to April 2019, patients with complicated type B aortic dissection, thoracic aortic aneurysm > 5.5 cm in diameter, or aortic penetrating ulcer with a base > 20 mm or depth > 15 mm, who received TEVAR requiring a proximal sealing beyond zone 3 and underwent ISF using an adjustable puncture device, were included. After the procedure, patients were monitored at one, three, six, and 12 months, and annually thereafter. Peri-operative and follow up data were collected and analysed.

RESULTS

Fifty of 51 patients (98%) received successful ISFs. One, two, or three aortic arch branches were preserved in 44, six, and one patient, respectively. Intra-operatively, eight type Ia endoleaks and one type II endoleak were found on angiography. One patient died of cerebral hernia three days post-procedure from a severe stroke; one patient suffered from transient paraplegia but recovered in two weeks; one patient had a non-disabling stroke. The median follow up was 31 months (22.5 - 36.5 months). At six month follow up, all nine unmanaged endoleaks had disappeared. One new type Ia endoleak was identified in a patient at the one month follow up which resolved spontaneously one year later. All revascularised arteries were patent at the last follow up. No fractures, migrations, or bridging stent kinks were found.

CONCLUSION

In this largest mechanical based ISF study to date, an adjustable puncture device was shown to facilitate the procedure of ISF during endovascular repair of aortic diseases involving the aortic arch, with high success. The midterm outcome demonstrates the efficacy and safety of the device in assisting with preservation of aortic arch branches.

A systematic review of experimental and clinical studies reporting on in situ laser fenestration of aortic endografts

OBJECTIVE

To summarize available in-situ laser fenestration (ISLF) literature, including experimental studies with their subsequent recommendations regarding optimal fenestration technique and fabric; as well as the short and mid-term results of clinical studies.

METHODS

A systematic review of English articles was performed in MEDLINE, the Cochrane Database and EMBASE, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines by two researchers. The search period was without starting date until the 31^st August 2020, and search terms included were in situ, laser, fenestration, and endograft. Quality assessment of the studies was performed using the Newcastle-Ottawa scale by two other independent researchers.

RESULTS

A total of 19 clinical studies were included, with a total of 428 patients (390 supra-aortic trunk ISLF, 38 visceral vessel ISLF). The technical success was 96.9% and 95.6% supra-aortic and visceral vessel ISLF, respectively. Most studies have less than 12-month follow-up, and the longest available follow-up (in one study) was 5-years for left-subclavian fenestration and 17-months for visceral vessel ISLF. Overall, the quality of the evaluated clinical studies was low. Six experimental studies were included, with the highest level of evidence suggesting fenestration of multifilament polyethylene terephthalate grafts, followed by dilation with either a 6- or 8-mm non-compliant balloon.

CONCLUSION

Experimental studies favour the use of multifilament polyethylene terephthalate , followed by dilation with non-compliant balloons as the most durable "in-vitro" technique for ISLF. Short-term outcomes for arch and visceral vessel revascularization are promising, with low rates of in-hospital mortality, stroke, and end-organ ischemia. Nonetheless, the long-term durability of ISLF is yet to be determined and they should be limited to selected symptomatic or urgent cases.

Aortic Dissection: Branched, Fenestrated, and Parallel Aortic Stent Grafts in the Ascending Aorta and Arch

Open surgical repair of dissections and post-dissection degenerative aneurysms involving the ascending thoracic aorta and aortic arch, whether in the acute or post-repair state, is associated with high rates of morbidity and mortality. Recent advancements in minimally invasive endovascular techniques have expanded the role of thoracic endovascular aortic repair (TEVAR) for dissections and dissection-related arch pathologies. Image-guided endovascular techniques, such as in situ fenestrated grafts, chimney and/or periscope grafts, along with newly developed commercially available branched aortic devices, have allowed for an increasing number of high-risk operative candidates to undergo definitive repair of aortic arch pathology who otherwise would have been destined for non-operative management. This paper reviews the data, pre-procedural planning, and technical considerations for complex TEVAR techniques for ascending and aortic arch dissections and dissection-related aneurysms.

Outcomes of Total Endovascular Aortic Arch Repair with Surgeon-Modified Fenestrated Stent-Grafts on Zone 0 Landing for Aortic Arch Pathologies

OBJECTIVES

This study evaluated the feasibility and safety of total endovascular aortic arch repair with surgeon-modified fenestrated stent-graft on zone 0 landing for aortic arch pathologies.

METHODS

Between June 2016 and October 2019, 37 consecutive patients underwent total endovascular arch repair with surgeon-modified fenestrated stent-grafts on zone 0 landing. Outcomes included technical success, perioperative and follow-up morbidity and mortality, and branch artery patency.

RESULTS

During the study period, 37 patients were treated with total endovascular aortic arch repair with surgeon-modified fenestrated stent-graft. Twenty-one (56.8%) patients were diagnosed with aortic dissections, 15 (40.5%) patients with aneurysms, and 1 (2.7%) patient required reintervention due to endoleak and sac expansion from previous thoracic endovascular aortic repair for thoracoabdominal aneurysm. The proximal landing zone for all patients were in zone 0, and all branch arteries of aortic arch were reconstructed. Technical success was achieved in 34 cases (91.9%). Three (8.1%) patients had fenestrations misaligned with target arteries, and the chimney technique was applied as a complementary measure. Thirty-day mortality rate was 5.4% (n=2). Thirty-day stroke rate was 5.4% (n=2). Thirty-day reintervention rate was 2.7% (n=1). At a median follow-up of 20 months (range, 3-49 months), 5 (13.5%) patients died, including 2 aortic-related deaths, 1 nonaortic-related death, and 2 deaths of unknown reason. One (2.7%) patient had stroke. Four patients (10.8%) had reintervention during the follow-up, including 2 cases of left subclavian artery occlusion and 2 cases of type II endoleak. The estimated survival (±SE) at 2 years was 72.4%±9.7% (95% CI 53.4%-91.4%). The estimated freedom from reintervention (±SE) at 2 years was 87.4%±5.9% (95% CI 75.84%-98.96%).

CONCLUSIONS

Total endovascular aortic arch repair with surgeon-modified fenestrated stent-grafts on zone 0 landing is an alternate option for the treatment of aortic arch pathologies in experienced centers.

Laser in situ Fenestration in Thoracic Endovascular Aortic Repair: A Single-Center Analysis

BACKGROUND

Laser in situ fenestration (LISF) is an expanding technique for arch vessel revascularization in thoracic endovascular aortic repair (TEVAR). We present a single center's early and midterm outcomes using adjunctive LISF with TEVAR for treatment of various arch pathologies.

METHODS

24 patients underwent TEVAR with LISF (2017-2020). Patients were evaluated by an Aortic Team consisting of cardiothoracic and vascular surgeons and were deemed unfit for open surgical repair. Informed consent emphasized the procedure's off-label nature. Thoracic stent-grafts were sized by preoperative Computed Tomography Angiogram and intraoperative Intravascular Ultrasound, with oversizing determined by pathology. Extra-anatomic debranching was performed in staged or concurrent fashion based on urgency of repair and access site options for branch fenestration. A 2.3 mm Spectranetics laser was used, with access site determined at surgeon discretion. Covered balloon expandable stent-grafts were deployed with 0-10% oversizing.

RESULTS

In 24 patients, a total of 30 fenestrations were created (LSA N = 19, LCCA N = 3, Innominate N = 7, RSA N = 1) with 1 (N = 18) or 2 (N = 6) fenestrations/patient. Indications included aneurysm (8), chronic dissection with aneurysmal degeneration (8), acute dissection (4), intramural hematoma (2), and pseudoaneurysm (2). 13 cases were elective, and 11 were emergent. Technical success was 100%. 12 patients underwent concurrent (N = 8) or staged (N = 4) extra-anatomic bypass. The major complication rate was 21%, including stroke (N = 3) and 30-day mortality (N = 2). The overall complication rate was 58%. Over a mean follow up of 261 days (15-864 days), 7 patients (32%) have required reinterventions.

CONCLUSIONS

LISF for branch revascularization in TEVAR is technically feasible for treating various aortic arch pathologies, demonstrating practicality in both elective and emergent settings. With a morbidity and mortality profile that is favorable compared to that of open repair, LISF with TEVAR is a promising potential option for patients with complex arch pathology and prohibitive open surgical risk.

Endovascular treatment of the dissected proximal aortic arch: a systematic review

OBJECTIVES

Surgical repair of aortic dissection involving the proximal aortic arch is associated with higher morbidity and mortality, in particular when elderly high-risk patients are concerned. Endovascular treatments for this disease are under evaluation and some reports exist. We investigated the current use of catheter-based treatments for the dissected proximal aortic arch repair.

METHODS

We searched in PubMed and MEDLINE databases up to the end of June 2020 for studies on endovascular treatment of the dissected proximal aortic arch. Data on demographic, procedure and stent graft (SG) details, access route, mortality with cause of death, complications and follow-up were extracted. A systematic review on the employed technology, procedure and outcome was performed.

RESULTS

A total number of 15 articles (13 retrospective reports and 2 case reports) were deemed eligible and were included in the study. In total, 140 patients (mean age: 56.7 years in 106 cases) received endovascular treatments for the dissected proximal aortic arch (unspecific aortic dissection: 14; acute and subacute type A aortic dissection: 88; chronic type A aortic dissection: 23; type B aortic dissection with retrograde type A dissection: 15). The procedure strategy included unspecific thoracic endovascular aorta repair (TEVAR) (n = 8), TEVAR + supra-aortic debranching (n = 2), TEVAR + cervical bypass (n = 8), TEVAR + periscope SG (n = 12), TEVAR + chimney graft (n = 8), TEVAR + branched SG (n = 21) and TEVAR + fenestration (n = 81). Procedural success rate was 95.6% for 116 reported cases. Complications included endoleaks (postoperative: 2; late: 5), stroke (n = 4), late SG-induced new entry (n = 3) and new false lumen formation (n = 1). Hospital mortality was 5% (6 cases) in 13 reports (120 patients). The mean follow-up time was 26.2 ± 29.4 months and 2 patients died during follow-up.

CONCLUSIONS

As an alternative to surgery for high-risk patients with a dissected proximal aortic arch, the endovascular treatment seems to be promising in highly selected cases. Further studies with long-term results and specifically designed devices are required to standardize this approach.

A Novel Fenestrating Device, "Quick Fenestrater," for Reconstructing Supra-aortic Arteries In Situ during Thoracic Endovascular Aortic Repair

BACKGROUND

In situ fenestration (ISF) is an effective approach for reconstructing supra-aortic branches during thoracic endovascular aortic repair (TEVAR). A dedicated device is needed for ISF.

METHODS

The "Quick Fenestrater" (QF) underwent in vitro, animal-based, and initial clinical testing. In vitro, the polytetrafluoroethylene and Dacron aortic endografts were fenestrated using the QF, and the structure of the graft, fenestration hole, and shed particulate material were evaluated. Eight white swine had QF-aided ISF combined with TEVAR and bridge stent implantation. The outcomes were assessed using intraoperative angiography and biopsy. Finally, 13 patients were treated with QF-assisted ISF, combined with TEVAR, and the success rate, technical details, and intra- and post-operative complications were recorded.

RESULTS

The endograft structure was not damaged during in vitro testing. The fenestration hole was clean, and no particulate material was detected. In animal studies, all animals survived, the supra-aortic arteries were patent, and the endografts and bridge stents had normal morphology. In clinical studies, the technical success rate was 100%, and no fenestration-related neurological complications or death occurred. One patient had a local access-related hematoma perioperatively and recovered after conservative treatment. Three patients had type III endoleaks, which resolved with no additional treatment. During a mean follow-up of 22.1±6 months, no thoracic complications were identified, and the bridge stents were patent with no endoleaks. No adverse cerebrovascular events, cardiovascular events, or death occurred.

CONCLUSIONS

QF-assisted ISF is a safe and effective method for the reconstruction of supra-aortic branches during TEVAR. Intermediate-term follow-up results validate the application of the novel fenestration device.

Gimme' the Loop: Modifications to the Squid-Capture Technique for Laser-Fenestrated Thoracic Endografting

PURPOSE

Laser-fenestrated thoracic endovascular aortic repair (LfTEVAR) in the aortic arch with covering of the left subclavian artery (LSA) orifice is challenging. To optimize fenestration, the so-called squid-capture technique has been introduced. We present here a modification to the technique that may help improve time-efficiency and safety.

TECHNIQUE:

During the originally proposed squid-capture maneuver, the stent-graft is deployed in a preset snare wire loop, which is used to pull the stent graft toward the penetration device during in-situ fenestration. In preparation, the guidewire needs to be passed through the loop inside the aortic arch, which can be difficult and may predispose for embolic events. We propose here the creation of a "guidewire-through-snare-loop" configuration outside the body, which can then be reliably transferred into the aortic arch. The modified technique was successfully applied in a patient undergoing LfTEVAR for penetrating aortic ulcers.

CONCLUSION

The proposed modification may help facilitate the squid-capture technique for LfTEVAR while saving time and resources. Given that LfTEVAR is becoming more frequently used, it is important to ensure technical success and safety of the procedure.

In Situ Laser Fenestration for Delayed Left Subclavian Artery Revascularization Following Thoracic Endovascular Aortic Repair of Type B Aortic Dissection

In situ laser fenestration (ISLF) is currently used to reconstruct the aortic major branches during thoracic endovascular aortic repair (TEVAR). To our knowledge, there have been no reports on the application of ISLF for delayed revascularization of the LSA previously sealed in TEVAR. This report describes 5 patients who underwent ISLF for delayed LSA revascularization, with a technical success rate of 80%. No endoleakage occurred, and stents remained patent during more than 6-month follow-up. ISLF is an effective, safe and minimally invasive method for delayed revascularization of the LSA following TEVAR for type B aortic dissection (TBAD) when patients are selected appropriately.

Evaluation for the safety and effectiveness of the in situ fenestration system in TEVAR for aortic arch pathologies: protocol for a prospective, multicentre and single-arm study

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) has gradually become the mainstream therapy for aortic arch pathologies (AAP). Our centre developed the in situ fenestration (ISF) system according to years of clinical experience and technological innovation. This study aims to evaluate the safety and effectiveness of the innovative, self-developed ISF system in TEVAR for AAP.

METHODS AND ANALYSIS

The study is a prospective, multicentre and single-arm study. Patients diagnosed with AAPs in five centres on 1 January 2021 will be recruited and general TEVAR with ISF system will be performed. Clinical information and CT angiography images will be collected and recorded. Patients will be followed up for 5 years. Safety and efficacy endpoints are planned to be reported to evaluate this self-developed ISF system.

ETHICS AND DISSEMINATION

The study is a registry. We have registered the study on the Chinese Clinical Trial Registry website (http://www.chictr.org.cn/). This study has been approved by the Ethics Committee of Zhongshan Hospital Fudan University (B2020-371) and individual consents will be signed at the time of enrolment. We anticipate that this self-developed ISF system will result in favourable social and economic benefits. Findings will be disseminated in peer-reviewed journals to provide reference for future clinical practice.

TRIAL REGISTRATION NUMBER

ChiCTR1900026696.

Systematic Review on the Use of Physician-Modified Endografts for the Treatment of Aortic Arch Diseases

BACKGROUND

The total endovascular approach is in current evolution, and many series have described variable outcomes for branched technology, chimney techniques, or fenestrated repair; and even a combination of some of them. We aim to describe the current outcomes on physician-modified endograft for the treatment of arch diseases.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for this systematic review. The search was applied to MEDLINE, EMBASE, Google Scholar, and Cochrane Central Register of Controlled Trials. We used the following search terms in all possible combinations: home-made, physician-modified, surgeon-modified, on-table modification, hand-made, endograft, endovascular, aortic arch, and TEVAR: a thorough search of the English-language literature published until March 2020 was performed to identify studies using physician-modified endograft for the treatment of arch diseases. Only studies with treatment of 3 patients or more and with a minimum of 6-month follow-up were enrolled in the systematic review, whereas case reports were excluded from the analysis.

RESULTS

Six articles participated in the systematic review after the exclusions, including a total of 239 patients for analysis. Four high-volume centers provided data including a high rate of single fenestrations in zone 2, accounting for nearly 70% of the cases. About 80.3% were males, and 67.4% received urgent treatment mainly for acute/subacute dissection (64.4%). Thoracic aortic aneurysm and/or postdissection arch aneurysm was the second leading cause of treatment with 25.9%. There was a technical success of 93.7% reaching up to 98.3% when additional procedures were performed. The 30-day mortality, stroke/transient ischemic attack, paraplegia, and stent-induced new entry rates were 2.9%, 2.1%, 0.4%, and 0.4%, respectively; whereas, overall mortality of the study was 4.6% at a mean follow-up of 33.2 ± 14.8 months.

CONCLUSIONS

Endograft modification for aortic arch diseases' treatment demonstrates to be safe and highly effective, especially for aortic dissections needing single zone 2 fenestrations. Although outcomes achieved in the study seem encouraging, these are achieved at high-volume experienced centers, thus, they need to be judiciously evaluated, whereas proctoring may be a good alternative if one patient may benefit from the technique in an unexperienced center.