Left subclavian artery bridging stent fracture after in-situ laser fenestration during emergent thoracic endovascular aortic repair.

In-situ laser fenestration (ISLF) has been described as a viable option for urgent thoracic aortic aneurysm cases involving supra-aortic vessels. There are, however, limited data on its durability. Here, we present a case of a 70-year-old man with a symptomatic 13-cm thoracic aortic aneurysm extending proximally to the origin of the left subclavian artery (LSA). Emergent thoracic endovascular aortic repair with chimney stenting of the left common carotid artery and ISLF for the LSA was successfully performed. During the follow-up, a compression of the bridging stent to the LSA progressed to a stent fracture needing realignment. Despite ISLF's reported technical success, this case highlights the risk of bridging stent complications, emphasizing the need for a close follow-up.

A national census for the off-label treatment of complex aortic aneurysms.

OBJECTIVE: Despite regulatory challenges, device availability, and rapidly expanding techniques, off-label endovascular repair of complex aortic aneurysms (cAAs) has expanded in the past decade. Given the lack of United States Food and Drug Administration-approved endovascular technology to treat cAAs, we performed a national census to better understand volume and current practice patterns in the United States. METHODS: Targeted sampling identified vascular surgeons with experience in off-label endovascular repair of cAAs. An electronic survey was distributed with institutional review board approval from the University of Rochester to 261 individuals with a response rate of 38% (n = 98). RESULTS: A total of 93 respondents (95%) reported off-label endovascular repair of cAAs. Mean age was 45.7 ± 8.3 years, and 84% were male. Most respondents (59%) were within the first 10 years of practice, and 69% trained at institutions with a high-volume of off-label endovascular procedures for complex aortic aneurysms with or without a physician-sponsored investigational device exemption (PS-IDE). Twelve respondents from 11 institutions reported institutional PS-IDEs for physician-modified endografts (PMEGs), in-situ laser fenestration (ISLF), or parallel grafting technique (PGT), including sites with PS-IDEs for custom-manufactured devices. Eighty-nine unique institutions reported elective off-label endovascular repair with a mean of 20.2 ± 16.5 cases/year and ∼1757 total cases/year nationally. Eighty reported urgent/emergent off-label endovascular repair with a mean of 5.7 ± 5.4 cases/year and ∼499 total cases/year nationally. There was no correlation between high-volume endovascular institutions (>15 cases/year) and institutions with high volumes of open surgical repair for cAAs (>15 cases/year; odds ratio, 0.7; 95% confidence interval, 0.3-1.5; P = .34). Elective techniques included PMEG (70%), ISLF (30%), hybrid PMEG/ISLF (18%), and PGT (14%), with PMEG being the preferred technique for 63% of respondents. Techniques for emergent endovascular treatment of complex aortic disease included PMEG (52%), ISLF (40%), PGT (20%), and hybrid-PMEG/ISLF (14%), with PMEG being the preferred technique for 41% of respondents. Thirty-nine percent of respondents always or frequently offer referrals to institutions with PS-IDEs for custom-manufactured devices. The most common barrier for referral to PS-IDE centers included geographic distance (48%), longitudinal relationship with patient (45%), and costs associated with travel (33%). Only 61% of respondents participate in the Vascular Quality Initiative for complex endovascular aneurysm repair, and only 57% maintain a prospective institutional database. Eighty-six percent reported interest in a national collaborative database for off-label endovascular repair of cAA. CONCLUSIONS: Estimates of off-label endovascular repair of cAAs are likely underrepresented in the literature based on this national census. PMEG was the most common technique for elective and emergent procedures. Under-reported off-label endovascular repair of cAA outcomes data appears to be limited by non-standardized PS-IDE reporting to the United States Food and Drug Administration, and the lack of Vascular Quality Initiative participation and prospective institutional data collection. Most participants are interested in a national collaborative database for endovascular repair of cAAs.

In situ laser fenestration of the Thoraflex Hybrid frozen elephant trunk for emergent revascularization of the left subclavian artery and laser fenestration for spinal cord perfusion.

In situ laser fenestration (ISLF) has emerged as a promising technique for emergent revascularization of the left subclavian artery in the case of thoracic endovascular aortic repair coverage, presenting excellent technical success rates in most studies. We describe a case of ISLF of the Thoraflex Hybrid frozen elephant trunk device to achieve immediate left subclavian artery revascularization. We demonstrate the feasibility and technical success of using ISLF in this setting, providing a less invasive alternative to conventional surgical revascularization when required.

Off-the-Shelf Single-Fenestrated Endograft for Emergent Juxtarenal and Pararenal Abdominal Aortic Aneurysm.

INTRODUCTION: Endovascular solutions to emergent juxtarenal and pararenal abdominal aortic aneurysms (AAAs) are complicated. Endovascular aortic repair (EVAR) with in situ laser fenestration (ISLF) is promising but requires a period of visceral ischemia. With an off-the-shelf, single superior mesenteric artery (SMA)-fenestrated device mesenteric ischemia is avoided and renal ischemia decreased. The aim was to develop an optimized design of such an endograft suitable for >90% of juxtarenal and pararenal AAAs. METHODS: Single-center analysis on 44 consecutive preoperative CTs for previously elective fenestrated EVARs for juxtarenal and pararenal aneurysms. Anatomical characteristics were analyzed to define: (1) shortest aortic coverage above SMA fenestration to achieve ≥4 cm seal; (2) feasibility of a scallop for the celiac artery; (3) shortest distance between the SMA and lowest renal, to facilitate renal ISLF in a straight endograft; (4) distance from the lowest renal to the aortic bifurcation, to allow an overlapping zone >40 mm with a bifurcated stent graft; (5) aortic diameter in the sealing zone, for optimal proximal stent graft diameter with 10% to 30% oversizing; (6) the final design was then tested on individual level. RESULTS: (1) The stent graft needs to start 40 mm above the SMA fenestration to achieve a 4 cm sealing zone in >90% of cases. (2) A proximal sealing zone of 40 mm without a scallop covers 77% of celiac arteries. With an addition of a 20 mm deep, 20 mm wide scallop at 12:30, the stent graft still covers 27% of celiacs. This suggests that a scallop would not be practically feasible. (3) In >90% of cases, the lowest renal was <31 mm from the SMA, suggesting that the tapering should start 30 mm below the SMA. (4) The distance from the lowest renal to the aortic bifurcation ranged from 82 to 166 mm. This allows for a 20 mm tapering and 50 mm straight part in all cases. (5) The 5th and 95th percentile of the aortic diameter in the sealing zone was 22 and 31 mm, respectively. Thus, 2 different stent graft diameters (28 and 34 mm) would fit >90% of cases. (6) The final design was suitable in 91% cases. CONCLUSIONS: Two sizes of a single-fenestrated aortic stent graft without scallop cover >90% of juxtarenal and pararenal anatomies. CLINICAL IMPACT: Emergent juxta- and pararenal aortic aneurysms is a difficult clinical scenario that continuously challenges physicians. An endovascular option is in situ laser fenestrated endografts. One risk with these is the complete visceral ischemia occurring before the fenestrations are completed. An off-the-shelf single-fenestrated stent graft facilitates the treatment by removing the ischemia time for the SMA and reducing the ischemia time for the celiac and renal arteries thus decreasing the risk of visceral ischemia complications.

Urgent endovascular mycotic aortic arch aneurysm repair using in situ laser fenestration and selective arterial perfusion with venoarterial extracorporeal membrane oxygenation.

In recent years, mycotic aortic aneurysms have been increasingly treated successfully by endovascular means. The introduction of custom-made fenestrated and branched devices, parallel graft techniques, and in situ fenestration has enabled total endovascular treatment also for arch pathologies. We describe a total endovascular repair of a mycotic arch aneurysm with in situ laser fenestration using venoarterial extracorporeal membrane oxygenation to preserve flow to vital organs.

Integration of a Custom-Made Fenestration to Simplify Acute Reno-Visceral In Situ Aortic Repair.

PURPOSE: To illustrate the technique of antegrade in situ laser fenestration (ISLF) on a predesign custom-manufactured stent-graft with single reinforced fenestration for use in emergency endovascular repair of complex abdominal aortic aneurysms (AAAs). TECHNIQUE: A short custom-made device (CMD) fenestrated graft was predesigned with a single preloaded 8 mm strut-free fenestration at 12 o'clock position. A modified preloaded system was used to allow unilateral access from the distal port if necessary. After bilateral percutaneous femoral access, the graft was deployed under fusion guidance with the CMD fenestration matching the superior mesenteric artery (SMA) origin and immediately bridged as per standard technique. The aneurysm was then excluded with a bifurcated device. A large steerable sheath was used to allow for sequential antegrade laser in situ fenestration and stenting of the renal arteries. CONCLUSIONS: Single-vessel customized short fenestrated grafts for the SMA and antegrade in situ laser renal fenestrations are technically feasible for repair of acute complex AAAs even after previous infrarenal reconstruction. It could become an off-the-shelf solution to limit aortic coverage and reno-visceral ischemia, even in patients with a narrow aortic diameter at the renal level. CLINICAL IMPACT: Single-vessel precustomized short fenestrated grafts for the SMA combined with renal artery antegrade ISLF can be a feasible option for the acute repair of patients with complex aneurysms and a narrow aortic diameter at the reno-visceral segment. It may limit aortic coverage and reno-visceral ischemic time and also be applicable after previous infrarenal endovascular aneurysm repair (EVAR).

Techniques of antegrade in situ laser fenestration for endovascular aortic repair of complex abdominal and thoracoabdominal aortic aneurysms.

Antegrade in situ laser fenestration allows for incorporation of visceral and renal arteries during endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms. This technique can be particularly useful for urgent and emergent cases and for centers without access to manufactured fenestrated-branched endovascular aneurysm repair devices. In the present report, we have described two techniques of antegrade in situ fenestration, the common pitfalls, and the anatomic considerations for each technique.

Comparative early results of in situ fenestrated endovascular aortic repair and other emergent complex endovascular aortic repair techniques for ruptured suprarenal and thoracoabdominal aortic aneurysms at a regional aortic center.

INTRODUCTION: Emergent endovascular repair of suprarenal (SRAAAs) and thoracoabdominal aortic aneurysms (TAAAs) poses a significant challenge due to the need for branch vessel incorporation, time constraints, and lack of dedicated devices. Techniques to incorporate branch vessels have included parallel grafting, physician-modified endografts, double-barrel/reversed iliac branch device, and in situ fenestration (ISF). This study describes a single-center experience and the associated outcomes when using these techniques for ruptured SRAAAs and TAAAs. METHODS: A retrospective review of patients who underwent endovascular repair of ruptured SRAAAs and TAAAs from July 2014 to March 2021 with branch vessel incorporation was performed. Clinical presentation, intraoperative details, and postoperative outcomes of those who underwent ISF were compared with those who underwent repair using non-ISF techniques. The primary outcome of interest was in-hospital mortality. Secondary outcomes were major adverse events including myocardial infarction, respiratory failure, renal dysfunction, new onset dialysis, bowel ischemia, stroke, and spinal cord ischemia. RESULTS: Forty-two patients underwent endovascular repair for ruptured SRAAAs and TAAAs, 18 of whom underwent ISF repair. Seventy-two percent of ISF patients were hypotensive before surgery, compared with 46% of the patients who underwent repair using non-ISF techniques (physician-modified endografts, parallel grafting, or double-barrel/reversed iliac branch device). The total procedural and fluoroscopy times were similar between the two groups despite a greater mean number of branch vessels incorporated with the ISF technique (3.1 vs 2.2 per patient, P = .015). In-hospital mortality was 19% for all ruptures and 25% for ruptures with hypotension. Compared with the non-ISF group, in-hospital mortality trended lower in the ISF group (11% vs 25%, P = .233), reaching statistical significance when comparing patients who presented with hypotension (8% vs 45%, P = .048). The rate of major adverse events was 57% across all techniques and did not significantly differ between the ISF and non-ISF groups, with postoperative renal dysfunction being the most frequent complication (48%). Overall, ISF became the most commonly used technique later in the study period. CONCLUSIONS: Although emergent endovascular repair of ruptured SRAAAs/TAAAs remains a challenge, a number of techniques are available for expeditious treatment. In this series, ISF was associated improve survival, including a fivefold reduction in mortality in patients presenting with hypotension, and has now become the dominant technique at our center. Despite these advantages, postoperative complications and reinterventions are common. Further experience and longer-term follow-up are needed to validate these initial results and assess durability.

In Situ Laser Fenestration for Delayed Left Subclavian Artery Revascularization Following Thoracic Endovascular Aortic Repair of Type B Aortic Dissection.

In situ laser fenestration (ISLF) is currently used to reconstruct the aortic major branches during thoracic endovascular aortic repair (TEVAR). To our knowledge, there have been no reports on the application of ISLF for delayed revascularization of the LSA previously sealed in TEVAR. This report describes 5 patients who underwent ISLF for delayed LSA revascularization, with a technical success rate of 80%. No endoleakage occurred, and stents remained patent during more than 6-month follow-up. ISLF is an effective, safe and minimally invasive method for delayed revascularization of the LSA following TEVAR for type B aortic dissection (TBAD) when patients are selected appropriately.

Antegrade in situ fenestrated endovascular repair of a ruptured thoracoabdominal aortic aneurysm.

We describe a technique for antegrade in situ laser fenestration that has several advantages in the setting of ruptured thoracoabdominal aortic aneurysms. This technique involves rapid aneurysm sealing by deployment of aortic stent graft, followed by sequential incorporation of branch vessels using a laser probe through steerable sheath. The advantages of this technique include (1) rapid seal of the ruptured aneurysm, (2) preservation of the visceral and renal branch perfusion, (3) use of an off-the-shelf device, and (4) the ability to be performed without general anesthesia.

Image Fusion Guidance for In Situ Laser Fenestration of Aortic Stent graft for Endovascular Repair of Complex Aortic Aneurysm: Feasibility, Efficacy and Overall Functional Success.

OBJECTIVE: To evaluate feasibility, efficacy and overall functional success of image fusion guidance during laser-assisted in situ fenestration of aortic stent graft (LISFAS) for endovascular repair of complex aortic aneurysm (complex-EVAR) in a prospective study. METHODS: Between September 2016 and July 2018, 20 patients were included and treated with LISFAS for complex-EVAR. Aortic aneurysms were either para-renal (n = 15) or thoraco-abdominal (n = 5) with 57 mm [first quartile: 54; third quartile: 68] median aneurysm diameter in 69 years [68;78] patients. All interventions were performed using the same angiographic system and 3D image fusion software for overlying pre-intervention CTA on per-intervention 2D fluoroscopy with cone-beam CT images to display target vessels ostia. RESULTS: LISFAS for complex-EVAR with image fusion was performed in all patients, and no endovascular intervention required conversion to an open aortic repair. LISFAS of all target vessels was feasible in 18 patients (90%); 48 fenestrations out of 50 were performed successfully. Two fenestrations failed for renal arteries in two patients. Median ischemic times were as follows: 34 min [25;43] for superior mesenteric artery; 69 min [56;83] for left renal artery; 73 min [36;102] for right renal artery; and 93 min [89;96] for the celiac trunk. Median intervention and fluoroscopy times, iodinated contrast volume and X-ray exposure were 180 min [150;180], 74 min [64;87], 80 mL [59;113] and 338 Gy.cm2 [259;495], respectively. Efficacy was found in 17 patients (85%) on one-week follow-up CTA: Two patients had type 1 and 3 endoleaks, respectively, that were successfully embolized. Overall functional success was 90%. Median hospitalization stay was 9 days [8, 17]. The 30-day safety analysis was 90% (n = 2 deaths) owing to an undetermined cause and to bowel ischemia after low flow in intensive care unit. CONCLUSIONS: LISFAS using image fusion was feasible, efficient and overall functionally successful for complex-EVAR in this preliminary study.

In Situ Laser Fenestration Is a Feasible Method for Revascularization of Aortic Arch During Thoracic Endovascular Aortic Repair.

BACKGROUND: Reconstruction of the aortic major branches during thoracic endovascular aortic repair is complicated because of the complex anatomic configuration and variation of the aortic arch. In situ laser fenestration has shown great potential for the revascularization of aortic branches. This study aims to evaluate the feasibility, effectiveness, and safety of in situ laser fenestration on the three branches of the aortic arch during thoracic endovascular aortic repair. METHODS AND RESULTS: Before clinical application, the polytetrafluoroethylene and Dacron grafts were fenestrated by an 810-nm laser system ex vivo, which did not damage the bare metal portion of the endografts and created a clean fenestration while maintaining the integrity of the endografts. In vivo, 6 anesthetized female swine survived after this operation, including stent-graft implantation in the aortic arches, laser fenestration, and conduit implantation through the innominate arteries and the left carotid arteries. Based on the animal experiments, in situ laser fenestration during thoracic endovascular aortic repair was successively performed on 24 patients (aged 33-86 years) with aortic artery diseases (dissection type A: n=4, type B: n=7, aneurysm: n=2, mural thrombus: n=7). Fenestration of 3 aortic branches was performed in 2 (8.3%) patients. Both the left carotid artery and the left subclavian artery were fenestrated in 6 (25%) patients. Only left subclavian artery fenestration surgery was done in 16 (66.7%) patients. Among these patients, 1 fenestration was abandoned secondary to an acute takeoff of the innominate artery in a type III aortic arch. The average operative time was 137±15 minutes. The technical success rate was 95.8% (n=23). No fenestration-related complications or neurological morbidity occurred after this operation. During a mean postoperative 10-month follow-up (range: 2-17 months), 1 patient died of severe pneumonia, and all the left subclavian artery and carotid artery stents were patent with no fenestration-related endoleaks upon computed tomography angiography images. CONCLUSIONS: In situ laser fenestration is a feasible, effective, rapid, repeatable, and safe option for the reconstruction of aortic arch during thoracic endovascular aortic repair, which might be available to revascularize the 3 branches. However, follow-up periods should be extended to evaluate the robustness of this technique.