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

Abstract

BackgroundReconstruction 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 ResultsBefore 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.ConclusionsIn 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.

Endovascular repair of aortic arch intramural hematoma and penetrating ulcers with 810 nm in situ laser‐assisted fenestration: Preliminary results of a single‐center

“…Unlike fenestration created with a needle and cutting balloon, the use of an energy laser has the potential to decrease the mechanical force required for puncture and the gross integrity of the fabric is always maintained . The graft used in the present study was tested in vivo before its application, and no significant tear was observed during fenestration with the 810 nm fiber lasers, which was consistent with previous research (Supplemental video). During follow‐up, no stent migration or endoleak occurred, which suggested that the connection between fenestration and stent was reliable.…”

Single-stage endovascular management of complicated thoracic aorta coarctation concurrent with aortic arch aneurysm using a novel fenestration device

“…Homemade needle, uncontrollable in strength and directional regulation, may also cause harm to surrounding tissue (14). Although current research has indicated that laser or mechanistic needle-guided procedure is effective during ISF for multiple supraaortic arteries (15), the case cohort is small so that the safety of these processes cannot be guaranteed. On the other hand, to substantiate whether QuickFenestrater can be a safer, more effective and efficient alternative than other traditional device for performing ISF to revascularize multiple supraaortic branches during TEVAR necessitates further clinical research.…”

Novel EM Guided Endovascular Instrumentation for In Situ Endograft Fenestration

“…Moreover, this procedure requires several readjustments of the C-arm pose (to optimize the viewing direction) which result in prolonged radiation exposure [2]. Finally, fenestrated grafts are customized to fit the patient anatomy, so their fabrication is expensive and time-consuming (tailored process can exceed 6 weeks [4]), and therefore they cannot be used for the emergency treatment of acute syndromes.…”