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In Situ Laser Fenestration for Zone 2 TEVAR: A 15 Year Experience Demonstrating Its Safety, Efficacy and Durability
William G. Montgomery, Fletcher Pierce, Ahmad Alsheekh, Fanny S. Allie-Cusson, Hosam F. El Sayed, Jean M Panneton
Eastern Virginia Medical School, Norfolk, VA
BACKGROUND:Retrograde in situ laser fenestration (RISLF) of the left subclavian artery (LSA) is a simple and effective method for left subclavian artery revascularization. However, long-term outcome data for this technique are lacking. This study aims to evaluate long-term outcomes of RISLF of the LSA in zone 2 thoracic endovascular aortic repair (TEVAR).
METHODS:A single-center retrospective review of 81 consecutive patients who underwent zone 2 TEVAR with LSA revascularization by RISLF was performed (2009-2024). This technique was performed through retrograde percutaneous or open brachial arterial access. A thoracic endograft was deployed in zone 2 followed by RISLF using a 2.3 mm laser. A balloon expandable covered stent was placed across the fenestration and post-dilated appropriately. Postoperative clinical follow-up and computed tomography angiography (CTA) were reviewed to assess laser fenestration-related outcomes. Our primary outcome was fenestration-related endoleaks (type Ic or IIIc). Secondary outcomes were post-intervention rates of cerebrovascular accidents (CVA), LSA stent patency, freedom from fenestration-related endoleak reintervention, fenestration-related mortality (FRM) and aortic-related mortality (ARM).
RESULTS: 81 patients were included in our series (48 male (59%), mean age 60.9 ±12.8 years). Indication for intervention was type B aortic dissection in 67 patients (82.7%). 92% of all interventions were urgent or emergent, with 19 patients presenting with rupture (23.5%). RISLF was successfully performed in all 81 cases with only two residual type 1a endoleaks noted at conclusion of the index operation. Median operative time was 153 minutes. Post-intervention CVA occurred in 3 patients (3.7%) and spinal cord injury in 6 patients (7.4%, 3 transient, 3 permanent). There were five (6.2%) early aortic-related mortalities with a median at 4 days postoperatively. Median clinical follow-up was 2.1 years (range 0-12.6) and median imaging follow-up was 2.6 years (range 0-12.5). 3 patients (3.7%) were found to have a type 1c endoleak and underwent distal extension of the LSA stent at 6.6, 23.6, and 30.2 months postoperatively. Importantly, there were no fenestration-related type IIIc endoleak or mortality. Primary LSA stent patency was 100% at 1 year, 96.7% at 5 years and 91.1% at 10 years (Figure 1A). Freedom from fenestration-related endoleak reintervention was 98.4% at 1-year, 93.2% at 5 years and 93.2% at 10 years (Figure 1B). There was only 1 late-aortic-related death (1.4%) secondary to rupture on postoperative day 77.
CONCLUSIONS:RISLF for LSA revascularization is a safe, reproducible, and durable treatment option in TEVAR requiring proximal seal in zone 2. RISLF carries an excellent technical success rate, low fenestration-related complications, and competitive long-term stent patency. Low stroke rate and operative time further support RISLF as an effective surgical technique for LSA revascularization.
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