Lengthening of proximal implantation site during endovascular repair of thoracic aortic aneurysm: Preservation of carotid patency with retrograde trans endograft deployment of a carotid stent

Abstract

Endovascular repair of descending thoracic aortic aneurysms with a reduced proximal implantation site represents a technical challenge. Surgical procedures before endovascular exclusion can be necessary to increase the length of the proximal landing site to avoid type 1 endoleaks. We present a case of endovascular exclusion of a descending thoracic aortic aneurysm with the endograft placed proximal to the left common carotid artery. Flow to this arch was preserved reconstructing the carotid ostium with the retrograde implantation of a carotid stent that was placed extending across an orifice created in the deployed endograft by puncture and balloon dilatation.

Clinical outcomes and material properties of in situ fenestration of endovascular stent grafts

“…Among the human clinical studies, there were 2 retrospective case series and 14 case reports representing a total of 44 patients and 46 fenestrated aortic branches. [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] Retrograde in situ fenestration technique. The feasibility of retrograde in situ fenestration was first demonstrated by McWilliams et al in 2003 using a canine model.…”

“…The feasibility of retrograde in situ fenestration was first demonstrated by McWilliams et al in 2003 using a canine model. Since then, three methods of in situ fenestration have been described: needle, 8,[10][11][12][13][14][15][16][17]20,[22][23][24][25][26][27][28][29][30][31][32] radiofrequency, 21,[33][34][35] and laser. 18,19 The main controversy associated with the use of in situ fenestration is the unknown long-term durability of an unreinforced fenestration.…”

In Vitro Fenestration of Aortic Stent-Grafts: Implications of Puncture Methods for in Situ Fenestration Durability

“…5 Retrograde puncture and balloon dilation of a thoracic endograft to fenestrate a left common carotid artery during endovascular exclusion of a descending thoracic aortic aneurysm has also been reported. 6 The feasibility of complete aortic arch reconstruction using the retrograde approach and conduit implantation with cerebral circulatory support was first demonstrated by Numan et al 7 in cadaveric and animal models; balloon-anchored needle dilators and radiofrequency (RF) plasma electrode catheters followed by balloon dilations were used to create fenestrations. Sonesson et al 8 applied this concept in the emergency clinical setting to treat an acute aortic arch rupture; cerebral flow was maintained using a temporary bypass from the left femoral artery to both carotid arteries.…”

“…[3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] Once the fabric has been breached, the fabric hole can then be dilated to a desired diameter and a branch stent can be placed to maintain perfusion of the target vessel. This technique can be performed in either a retrograde 3,4 (from within the lumen of the side branch, therefore requiring downstream access) or an antegrade (from within the lumen of the stentgraft) 16,17 fashion and may be potentially applied to all major aortic side branches.…”

Thoracic endovascular aortic repair in penetrating aortic ulcer combined with isolated left vertebral artery

“…In terms of TEVAR, multitude methods have been widely used in revascularization of arch branches, the vital step during the whole process, including chimney, in situ fenestration and customized endograft. However, customized graft is off-label in China, so that techniques including handmade needle, [6,7] radiofrequency, [8,9] and laser associated with dilation balloon (conventional or cutting) [10,11] were overwhelmingly chosen for in situ fenestration.…”