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.
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Author conflict of interest: Dr Panneton is a consultant and on the Speakers' Bureau for Cook Medical and Medtronic Inc.
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
