Midterm results of laser generated in situ fenestration of the left subclavian artery during thoracic endovascular aneurysm repair

OBJECTIVE: To analyze the midterm result of in situ fenestration (ISF) of the left subclavian artery (LSA) during thoracic endovascular aneurysm repair (TEVAR).

METHODS: In this clinical study, between 2014 and 2016, ISF for LSA revascularization was attempted during TEVAR in 10 patients (7 males; median age, 68 years). An excimer laser, placed from the left brachial artery, was used to create a fenestration and all fenestrations were stented with covered stent grafts. Follow-up included computed tomography scans 1 month postoperatively and annually thereafter. Survival was analyzed according to Kaplan-Meier.

RESULTS: Nine of the 10 laser-assisted ISF were successful. No 30-day mortality occurred. One patient had a transient ischemic attacked in the left carotid territory. After a median follow-up of 27 months, all fenestrations were patent. At 1 month, computed tomography follow-up showed nonspecific endoleaks of unknown origin in five of the nine patients. At 27 months follow-up, only two endoleaks remained. One reintervention was done after 24 months owing to a type Ic endoleak from the LSA. Overall TEVAR success, defined as survival with no aneurysm expansion, was eight of nine. One patient showed aneurysm expansion after 14 months. Two deaths occurred (at 33 and 31 months postoperative), one of unknown reason and one aneurysm related.

CONCLUSIONS: Laser fenestration might be an option for LSA revascularization during emergent or semiurgent TEVAR and electively in patients with hostile neck anatomy (eg, previous neck radiation, short and adipose necks) that might make a carotid-subclavian bypass difficult. The LSA fenestration has excellent patency and TEVAR success was not affected by nonspecific endoleaks around the LSA.