In situ laser fenestration during emergent thoracic endovascular aortic repair is an effective method for left subclavian artery revascularization

Abstract

Background: Retrograde laser fenestration of the left subclavian artery (LSA) during emergent thoracic endovascular aortic repair (TEVAR) uses a relatively simple intraoperative method of endograft modification to revascularize aortic branches for a variety of acute thoracic aortic pathologies. This study presents our expanded experience and midterm outcomes of TEVAR with laser fenestration to revascularize the LSA as an alternative to debranching.

Methods: Patients who underwent TEVAR with LSA revascularization by laser graft fenestration from September 2009 through August 2012 were retrospectively reviewed. TEVAR was performed with deployment of a Dacron (DuPont, Wilmington, Del) endograft over the LSA orifice. Laser catheter fenestration of the graft was performed through retrograde brachial access, followed by balloon-expandable covered stent deployment through the fenestration to traverse the endograft and LSA. Routine postoperative follow-up imaging with computed tomography angiography was performed to assess TEVAR and LSA fenestration patency, endoleak, and aneurysm/dissection exclusion.

Results: TEVAR with laser fenestration was successfully performed in 22 patients (12 men; mean age, 57 years) in an urgent or emergent setting secondary to unremitting symptoms or rupture. Twelve patients had large symptomatic thoracic aortic aneurysms (eight secondary to chronic dissection); four patients had acute symptomatic type B aortic dissection, and six patients had an intramural hematoma or penetrating aortic ulcer, or both. An average of two endografts (range, 1-4) were deployed. LSA-covered stents were 8 to 10 mm in diameter. Mean operative time was 154 ± 65 minutes. Average hospital length of stay was 12 ± 7 days. No major fenestration-related complications occurred. One patient developed postoperative paraplegia. One patient died in the postoperative period, for an in-hospital mortality rate of 4.5%. Two patients died of non-TEVAR-related causes at a mean follow-up of 10 months (range, 1-40 months). Follow-up computed tomography angiography imaging demonstrated a 100% primary patency for the LSA stents. One patient had an asymptomatic LSA stent stenosis. Type II endoleaks from the LSA in two patients required endovascular coil embolization. No fenestration-related type I or III endoleaks were noted.

Conclusions: In situ retrograde laser fenestration is a feasible and effective option for LSA revascularization during TEVAR involving a spectrum of acute thoracic aortic pathology. Laser fenestration provides a rapid, reproducible method of fenestrating the endograft material. The high technical success, low fenestration-related morbidity, and excellent midterm patency support this technique of intraoperative endograft modification.