In Situ Needle Fenestration during Thoracic Endovascular Aneurysm Repair: Successful Fenestration of Two Overlapping Thoracic Stent Grafts.

Endovascular stent grafting is becoming more common in treating complex thoracic aortic aneurysms and dissections. When it becomes necessary to cover the supra-aortic vessels, maintaining blood supply through the supra-aortic branches can be achieved by performing in situ needle fenestration. We present a case of a 65-year-old man with a type B aortic dissection that extended from the origin of the left subclavian artery. A stent graft was inserted into the thoracic aorta distally of the origin of the left common carotid artery. Due to the stent graft moving distally and not adequately sealing the subclavian artery, a second stent graft was placed more proximally. Both stent grafts were successfully in situ fenestrated using a needle, and a stent graft was inserted into the subclavian artery. In conclusion, during thoracic endovascular aortic repair, in situ needle fenestration can be successfully carried out on two overlapping thoracic stent grafts.

Selective cerebral extracorporeal circulation-enhanced total endovascular arch replacement using in situ fenestration.

In this article, we present a newly designed cerebral perfusion technique during the in situ fenestration procedure with three covered stent placement in an endovascular total aortic arch repair of a 68-year-old male patient. This technique enables the endovascular repair of the ascending aorta and aortic arch pathologies with commonly available thoracic aorta stent grafts in a safer and more effective manner.

In Situ Fenestration and Carotid-Subclavian Bypass for Left Subclavian Artery Revascularization During Thoracic Endovascular Aortic Repair.

PURPOSE: To evaluate the safety and feasibility of left subclavian artery (LSA) revascularization techniques during thoracic endovascular aortic repair (TEVAR)-the in situ needle fenestration (ISNF) technique and the carotid-subclavian bypass (CS-Bp)-for complicated aortic pathologies. METHODS: A retrospective single-center observational study was conducted to identify all patients with thoracic aortic pathologies who underwent TEVAR with LSA revascularization using either CS-Bp or ISNFs from January 2014 to December 2020. RESULTS: One hundred and twelve consecutive patients who received TEVAR with LSA revascularization were included. Among them, 69 received CS-Bp and 43 received ISNF (29 using the Futhrough adjustable puncture needles, 14 using the binding stent-graft puncture systems). Technical success, defined as achieving aortic arch pathology exclusion and LSA preservation, was attained in 99.1% patients. Early mortality was 0.9%. Major adverse events within 30 days, including one cerebral hemorrhage, one cervical incision hemorrhage, one stroke and two paraplegia, were exclusively observed in the CS-Bp group. Immediate type I, II and III endoleaks occurred in 0%, 4.7% and 2.3% in the ISNF group, respectively, compared to 0%, 2.9% and 0% in the CS-Bp group.One hundred and eight (97.2%) patients were available for follow-up at a median 50 (maiximum of 103) months, revealing a LSA patency rates of 99.1%. Six patients died during follow-ups-five in the CS-Bp group and one in the ISNF group. Cause of death include one aortic-related stent-graft infection, three non-related and two with unknow causes. The survival exhibited no significantly different between the ISNF (97.7%) and CS-Bp (89.9%) groups (p = 0.22). CONCLUSIONS: Both CS-Bp and ISNF are feasible techniques for LSA reconstruction in TEVAR. ISNF, whether using Futhrough or BPS, seems to be competitive with CS-Bp.