A systematic review of experimental and clinical studies reporting on in situ laser fenestration of aortic endografts

Prendes, Carlota Fernández; Lindström, David; Mani, Kevin; Tegler, Gustaf; Wanhainen, Anders

doi:10.1016/j.jvs.2021.09.031

Cited by 26 publications

(7 citation statements)

References 42 publications

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“…These results are similar to the findings in a recently-published systematic review. 13 In addition to the difficulties of making a fenestration in C-TAG (made from expanded polytetrafluoroethylene [ePTFE] fabric), there are previous reports of hazardous chemicals by-production when polytetrafluoroethylene (PTFE) and/or ePTFE is exposed to thermal energy. 15 – 17 As a result, despite otherwise appealing features of the C-TAG in endovascular treatment of the thoracic aorta, 18 the creation of ISLF by means of the 308 nm CVX-300 Excimer Laser System in C-TAG cannot be encouraged.…”

Section: Discussionmentioning

confidence: 99%

“…12 A recent review found that dilatation should be done with standard noncompliant balloons and not exceed 8 mm in diameter. 13 In 2020, a laser system (Philips Excimer CVX-300) was introduced at the authors' University Hospital to provide endovascular treatment for patients who presented with acute aortic pathology not suitable for open surgery. Given the limited evidence on optimal laser technique, the aim of our study was to assess how the aortic endografts respond to laser fenestrations and how the bridging stent-grafts will behave in the ISF created using laser technology.…”

Section: Introductionmentioning

confidence: 99%

“… 12 A recent review found that dilatation should be done with standard noncompliant balloons and not exceed 8 mm in diameter. 13 …”

Section: Introductionmentioning

confidence: 99%

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In Situ Laser Fenestration Technique: Bench-Testing of Aortic Endograft to Guide Clinical Practice

2022

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Purpose: In situ laser fenestration (ISLF) is a recently introduced technology that offers the potential to perform total endovascular treatment of aortic arch and thoracoabdominal aortic pathologies in the acute setting. This experiment’s aim was to assess ISLF in some currently common aortic endografts and bridging stent-grafts. Materials and Methods: Three different aortic endografts were evaluated: (1) Zenith Alpha, (2) Zenith TX2, and (3) Conformable GORE TAG. Each endograft was submerged in 37°C saline to create fenestrations using the 308 nm CVX-300 Excimer Laser System fitted with a 2.3 mm diameter Turbo-Elite laser atherectomy catheter compatible with a 0.018″ guidewire. Three different 8 mm bridging stent-grafts were evaluated: (1) BeGraft peripheral, (2) BeGraft peripheral plus, and (3) GORE VIABAHN VBX Balloon Expandable. All bridging stent-grafts were deployed and exposed to different balloon sizes and pressures. The ISLFs and bridging stent-grafts were then evaluated for any tears, stenoses, and seal. Results: A laser fenestration was consistently rapidly obtained in the Zenith Alpha and the Zenith TX2 endografts while it proved difficult to achieve a timely fenestration in the C-TAG. No fabric tears were noted in the Zenith Alpha and Zenith TX2 when inflating Armada (Abbott) 8 mm balloon in the fenestrations with pressures up to 15 atmospheres (rated burst pressure) nor when flaring bridging stent-grafts with balloons up to 12 mm in diameter at 10 atmospheres, while major tears were frequently noted in the C-TAG when the Armada 8 mm balloons were inflated. BeGraft Peripheral and BeGraft Peripheral Plus were all firmly attached to the fenestrations showing good seal on manual testing, while every sixth VBX bridging stent-graft displayed poorer attachment to the fenestration before dilatation at high pressure. Commonly, significant stenoses remained in the bridging stent-grafts after dilatation at nominal pressure, which could only be eradicated with high-pressure balloons. Conclusion: In this limited bench-test, Dacron endografts responded well to the ISLF technology. Satisfactory deployment of the bridging stent was noted only after inflation and/or flaring with high-pressure balloons. Further work with different types of commercially-available bridging stent-grafts and endografts to assess the durability of in situ fenestration (ISF) and bridging stents in ISF is recommended. Clinical Impact This report on experimental in situ laser fenestration provide important insights for clinicians considering using in situ laser fenestration of aortic stentgrafts in vivo. In particular, different laser settings were tested together with a selection of aortic stentgrafts. Also, the target pressure needed in PTA balloons to dilate the fenestrations and any subsequent tears in the fabric were noted. This was followed by deployment of assorted balloon-expandable stentgrafts with estimation of residual stenosis and seal.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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In Situ Laser Fenestration Technique: Bench-Testing of Aortic Endograft to Guide Clinical Practice

2022

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“…In situ laser fenestration (ISLF) has emerged as a new promising technique for emergent revascularization of the LSA, presenting excellent technical success rates of >95% in most studies and an LSA patency rate of 97% to 100%. 2 Previous studies have shown that Dacron-based stent grafts (eg, Zenith Alpha; Cook Medical Inc) are suitable for the ISLF technique. In contrast, polytetrafluoroethylene-based stent grafts (eg, Gore cTAG; W.L.…”

mentioning

confidence: 99%

“…Gore & Associates) should be avoided due to the potential liberation of toxic molecular substances after thermal ablation, the difficulty to perforate using a laser, and the propensity for fabric tears on dilatation of the fenestration. 2 , 3 …”

mentioning

confidence: 99%

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

Shehab,

Wanhainen,

Tegler

et al. 2024

Journal of Vascular Surgery Cases, Innovations and Techniques

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

Fan,

Fang,

Tian

et al. 2024

Cardiovasc Intervent Radiol

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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. Graphical Abstract

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A systematic review of experimental and clinical studies reporting on in situ laser fenestration of aortic endografts

Cited by 26 publications

References 42 publications

In Situ Laser Fenestration Technique: Bench-Testing of Aortic Endograft to Guide Clinical Practice

In Situ Laser Fenestration Technique: Bench-Testing of Aortic Endograft to Guide Clinical Practice

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

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