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Purpose: To evaluate outcomes of homemade fenestrated stent-grafts for complete endovascular aortic repair of aortic arch dissections. Materials and Methods: From July 2014 through September 2018, 35 patients (mean age 66±11 years; 25 men) underwent homemade fenestrated stent-graft repair of acute (n=16) or chronic (n=10) complicated type B aortic dissections (n=16) and dissecting aortic arch aneurysms subsequent to surgical treatment of acute type A dissections (n=9). Nineteen (54%) procedures were emergent. Results: Zone 2 single-fenestrated stent-grafts were used in 25 cases; the remaining 10 were double-fenestrated stent-grafts deployed in zone 0. Median time for stent-graft modification was 18 minutes (range 16–20). Technical success was achieved in all cases. An immediate distal type I endoleak was treated intraoperatively. Among the double-fenestrated stent-graft cases, the left subclavian artery fenestration could not be cannulated in 2 patients and revascularization was required. Partial coverage of the left common carotid artery necessitated placement of a covered stent in 3 cases. One (3%) patient had a stroke without permanent sequelae. Two type II endoleaks required additional covered stent placement at 5 and 7 days postoperatively, respectively. The 30-day mortality was 6% (2 patients with ruptured aortic arch aneurysm). During a mean follow-up of 17.6±13 months, there was no aortic rupture or retrograde dissection. One late type I endoleak was treated with additional proximal fenestrated stent-graft placement. One type II endoleak is currently under observation. One additional patient died (unrelated to the aorta); overall mortality was 9%. All supra-aortic trunks were patent. Conclusion: The use of homemade fenestrated stent-grafts for endovascular repair of aortic arch dissections is feasible and effective for total endovascular aortic arch repair. Durability concerns will need to be assessed in additional studies with long-term follow-up.

Purpose: To investigate the midterm outcomes of scalloped or fenestrated physician-modified endovascular grafts (PMEGs) for zone 2 thoracic endovascular aortic repairs (TEVAR). Materials and Methods: Between November 2013 and May 2019, 54 consecutive patients (mean age 63 years; 41 men) were treated with thoracic PMEGs modified with 7 scallops or 47 fenestrations for the left subclavian artery (LSA). Indications for aortic repair were acute complicated type B aortic dissection (17, 31%), degenerative aneurysm (13, 24%), acute traumatic rupture of the aortic isthmus (9, 16%), post chronic dissection aneurysmal evolution (8, 15%), penetrating aortic ulcer (3, 6%), intramural hematoma (2, 4%), and floating thrombus (2, 4%). Results: Technical success was 94%; 3 (6%) LSAs were unintentionally covered. An intraoperative type Ia endoleak was treated during the index procedure. One (2%) patient suffered spinal cord ischemia, with irreversible bilateral paraplegia. Three (6%) patients experience postoperative minor strokes with full neurological recovery. Four (7%) patients died in the perioperative period; 2 (2%) were due to aneurysm rupture. Mean follow-up was 26±16 months; 15 (28%) patients had at least 3 years of follow-up. Two (4%) type II endoleaks were identified and successfully treated (4% reintervention rate); no other endoleaks were identified. All the LSAs remained clinically and radiologically patent. There were no conversions to open repair, ruptures, retrograde dissection, stent fracture, migrations, or other aortic complications. Conclusion: Scalloped or single-fenestrated PMEGs for the LSA appear to be durable and safe in the midterm. Combined with low periprocedural morbidity and mortality, these results suggest that this approach can be considered as an off-label alternative to extend proximal seal to zone 2 for TEVAR. Further studies with a larger number of patients and long-term outcomes are needed to fully validate this approach.

Objective: Our aim was to evaluate the early-and medium-term outcomes of using double fenestrated physicianmodified endovascular grafts (PMEGs) for total endovascular aortic arch repair.Methods: The present single-center retrospective analysis of prospectively collected data included 50 patients from January 2017 through October 2019, who had undergone thoracic endovascular aortic repair (TEVAR). The fenestrations were a proximal larger fenestration that incorporated the brachiocephalic trunk and left common carotid artery and a distal smaller fenestration for the left subclavian artery (LSA). Only the LSA fenestration was stented.Results: The median duration for stent graft modification was 26 6 6 minutes. Of the 50 patients, 41 were men. The mean patient age was 68 6 11.5 years. The indications for treatment included degenerative aortic arch aneurysm (n ¼ 17), dissecting aortic arch aneurysm after type A dissection (n ¼ 13), type B dissection (n ¼ 13), aortic ulcer (n ¼ 3), and other pathologies (n ¼ 4). The technical success rate was 94% (47 of 50) overall, and 100% (28 of 28) after a technical modification incorporating a preloaded guide wire for the LSA fenestration (P < .05). The 30-day mortality was 2% (n ¼ 1). Two patients (4%) had a minor stroke with full recovery. One patient (2%) had a type IB and two patients (4%) had a type II endoleak from the LSA. Four patients (8%) required reintervention: one because of a type IB endoleak and three because of access-related complications. All supra-aortic trunks were patent. During a mean follow-up of 16 6 8.3 months, no conversions to open surgical repair were required and no aortic rupture, paraplegia, or retrograde dissection occurred.Conclusions: Using double fenestrated PMEGs for TEVAR is both feasible and effective for total endovascular aortic arch repair, avoiding the need for anatomic and extra-anatomic surgical revascularization. The absence of brachiocephalic trunk stenting was not associated with endoleaks or treatment failure and resulted in a lower stroke risk than alternative strategies. The midterm results suggest that stenting of the brachiocephalic trunk and right common carotid artery might not be necessary for a large proportion of patients undergoing total endovascular aortic arch repair. The persistence of the seal and ongoing durability require assessment in studies with long-term follow-up data available.

Purpose: To analyze the structural variation of the aortic arch and the supra-aortic arteries and establish an average spatial configuration that would be a pattern for a “universal double fenestration” design for physician-modified endovascular grafts (PMEGs) used in total thoracic endovascular aortic repair (TEVAR). Materials and Methods: Aortic arch morphology was retrospectively analyzed by reviewing the preoperative thoracic computed tomography angiography scans in 33 consecutive patients (mean age 68 years; 27 men) treated between January 2017 and March 2019 using double-fenestrated PMEGs for zone 0 TEVAR. Image analysis was completed according to a standardized technique on a vascular workstation with center lumen line reconstruction for all measurements. Variations in branching pattern of the aortic arch were classified into 8 types. Results: The arch trunk configuration was type I in 26 patients (79%), type II in 5 (15%), type III in 1, and type IV in 1. Mean aortic diameters at the level of mid ascending aorta, innominate artery (IA), left common carotid artery (LCCA), and left subclavian artery (LSA) were 35.7±3.7, 34.2±4.5, 33.3±6.7, and 33.7±4.7 mm, respectively. Mean diameters of the trunk were 12.2±1.7, 7.5±1.4, and 8.0±0.8 mm, respectively. Mean longitudinal center to center lengths were 15.9±2.5 mm between the LSA and LCCA and 12.1±3.0 mm between the LCCA and IA. Mean clock positions using the LSA as reference were 12:50 for the IA and 12:05 for the LCCA. In 32 patients (97%) all the supra-aortic branch vessels fit perfectly inside two delimited areas defined by a proximal common square area of 30×30 mm for the IA and LCCA and a second distal 8-mm-diameter circle for the LSA. Conclusion: Variations of the aortic arch anatomy are numerous and common. A general morphological pattern is described that delimits the aortic area where these variations occur. This information can be utilized for the design of an off-the-shelf double-fenestrated stent-graft for zone 0 TEVAR.