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INTRODUCTION: We have previously described our early experience utilizing retrograde laser fenestration to revascularize the left subclavian artery (LSA) during zone II thoracic endovascular aortic repair (TEVAR). This technique employs a relatively simple intraoperative method of endograft modification to revascularize aortic branches for a variety of acute thoracic aortic pathologies. The aim of this study is to present our expanded experience and midterm outcomes of TEVAR with laser fenestration to revascularize the left subclavian artery (LSA) as an alternative to debranching.
METHODS: A retrospective review of the electronic medical records was conducted of all patients who underwent TEVAR with LSA revascularization via laser graft fenestration from September 2009 through August 2012. TEVAR was carried out with deployment of a Dacron endograft over the orifice of the LSA. Through retrograde brachial access, a 0.018-inch guide wire was placed at the ostium of the LSA followed by laser catheter fenestration of the graft. Balloon expandable covered stents were deployed through the fenestration to traverse the endograft and LSA; the endograft portion of the covered stent was flared. Routine post-operative follow-up imaging with computed tomography angiography (CTA) was performed to assess for 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 of 57 years; range 37-83 years) in an urgent or emergent setting secondary to unremitting symptoms. Thirteen patients had large symptomatic thoracic aortic aneurysms (10 secondary to chronic dissection); 4 patients had acute symptomatic type B aortic dissection and 5 patients had intramural hematoma or penetrating aortic ulcer. An average of 2 endografts (range 1-4) were placed during TEVAR. LSA covered stents ranged in diameter from 8-10mm. Mean operative time for TEVAR with laser fenestration was 154±65 minutes. The average hospital length of stay was 12±7 days. There were no fenestration-related complications and one patient developed post-operative paraplegia. One patient died from massive hemoptysis in the post-operative period, for an in-hospital mortality rate of 4.5%. At a mean follow-up of 8 months (range 1-32), 2 patients had died (9%) of non-TEVAR related causes. Follow up CTA imaging demonstrated a 100% primary patency for the LSA stents. One patient had an asymptomatic LSA stent stenosis. Two patients had type II endoleaks from the LSA that required re-intervention. Both were successfully managed with endovascular coil embolization. There were no fenestration-related Type I or III endoleaks.
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 mid-term patency support this technique of intraoperative endograft modification. Longer follow-up remains necessary to determine the durability of this technique.