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Assessment of Long-Term Durability of Left Subclavian Retrograde In Situ Laser Fenestration in Thoracic Endovascular Aortic Repair
William G Montgomery, Fletcher Pierce, Jean Panneton
Eastern Virginia Medical School, Norfolk, VA

INTRODUCTION:Retrograde laser fenestration of the left subclavian artery (LSA) has been shown to be a relatively simple and effective intraoperative method for left subclavian artery revascularization. However, long-term outcomes of this technique have yet to be studied. The aim of this study is to present long-term clinical and radiographic outcomes on 33 patients who underwent TEVAR with retrograde laser fenestration of the LSA over a decade ago. METHODS: This is a retrospective study of 33 consecutive patients at a single institution who underwent zone 2 TEVAR with LSA revascularization by retrograde in situ laser fenestration between 2009 and 2013. While our institution’s database contains 97 patients having undergone TEVAR with retrograde laser fenestration of the great vessels, this study was designed to evaluate long-term durability of laser fenestration and therefore only included patients having undergone LSA laser fenestration 10 years ago or more. Laser fenestration was performed through retrograde brachial access, followed by covered stent deployment through the fenestration to traverse the endograft and LSA. Postoperative clinical follow-up and computed tomography angiography (CTA) were reviewed to assess late laser fenestration-related morbidity including reintervention, endoleak, and mortality. RESULTS: TEVAR with retrograde laser fenestration of the LSA was performed in 33 total patients (16 males, 17 females, aged 60.0 ±13.0 years). Mean operative time was 172.6 ± 89.1 minutes. Successful LSA stenting was achieved via retrograde laser fenestration in 100% of cases. Average hospital length of stay was 10.4 ± 9.2 days. Two patients experienced spinal cord ischemia with postoperative paraparesis (6.0%) and one experienced paraplegia (3.0%). Of note, one patient underwent repair of type 1c of LSA stent on postoperative day 8. Two patients died in the immediate 30-day postoperative period. Two additional patients were lost to follow-up within the first 30 days. Of the patients that maintained follow up to >30 days (n=29), they had a mean follow up length of 6.2 ± 4.3 years of imaging and 6.4 ± 4.1 years of clinical follow up. There have been eight late deaths including 1 aortic related mortality with a mean time to death of 2.7 years postoperatively. Importantly, there has been no fenestration-related mortality to date as well as no incidences of type III endoleak. CT imaging showed 96.6% rate of stent patency in the late postoperative period with one LSA stent found to be occluded yet asymptomatic 6.1 years after surgery. Two patients (6.9%) were found to have late type 1c endoleak and underwent distal extension of the LSA stent at 17.3 and 30.2 months postoperatively. CONCLUSIONS:Retrograde laser fenestration for LSA revascularization during TEVAR is a durable, long-term treatment option for management of aortic pathologies requiring proximal seal in zone 2. This technique provides a rapid, reproducible method of fenestrating the endograft material that is effective in emergent, urgent, and elective procedures. Laser fenestration carries an excellent technical success rate, low fenestration-related complications, and competitive long-term stent patency. Further efforts are warranted to investigate retrograde laser fenestration outcomes.
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